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Applications Will Be Processed When Submitted Properly Completed. BeSure iosign ineApplication. <br /> FOR OFFICE USE: APPLICATION <br /> �- (For Non-Transis cable, I�evocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with� Sang Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District./ `t-2- cr C City/Town <br /> Exact Site Address_ f� <br /> y _ I <br /> Owner's Name I + Phone r� <br /> rJ t city� � - - <br /> Address _ L� f���1 - <br /> Contractor's Name r � 1 l � License#�1J f l i Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLCBY DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> t <br /> Sewage Disposal Field Cesspool/Seepage Pit Other. <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL rl <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> M DOMESTIC/PRIVATE ®DRILLED Dia. of Well Casing �i <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casings - <br /> ❑ IRRIGATION ®'GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information Y <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximiate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inslection pr or to grouting and a final inspection. �j r <br /> Signed X"hk !:r'. "rw <br /> l�rg 1 1 -ooh- Date:lan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By � � Date <br /> Additional Comments: <br /> Phase II Grout Inspection ��/ GJ r Phase III Final Inspec <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8&Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ,/ O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY "? ' <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 85201 <br />