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4 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. s <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 4 Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordipgrice No. 1862 and the rules and regulations of the San J u n Local Health District. <br /> Exact Site Address_ a City/Town _ 1 <br /> r <br /> Owner's Name, Phone <br /> Address City <br /> Contractor's Name Business Phone -"", ;¢"� _A7_ <br /> t 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 WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT-E] OTHER ❑ PUMP INSTALLATION �/ PUMP REPAIR© . <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Wel! Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ' ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Q <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: „_,,r_Z?_5tate•Work-Dane- . - <br /> PUMP REPAIR: ❑ State Work'Done <br /> yr+ .� s <br /> DESTRUCTION OF WELL: WeII.Diameter---- _ -.Approximate Depth <br /> Describe Material and Procedure-'_ <br /> �� <br /> s <br /> I ► <br /> I 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:'tl-certify that iri 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 for which this <br /> permit is issued, I.-shall employ persons subject to workman's compensation laws of California." <br /> I Acall for a Grout Inspectio prior to grouting and a final inspection. <br /> Signed X - Title: �� �1� .� i!/�eDate: <br /> (Draw Plot Plan on Reverse Side) <br /> ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> .1, Phase II Grout Inspection. se III Final I ppection <br /> Inspection By__.��1 Date Inspection Sy ate <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> L� AMOUNT i <br /> FEE <br /> rr fir• 4 F. <br /> LESS – <br /> 7- PRORATION __,..,,.^,�..,._... - •'t _+ <br /> PLUS .4 _ <br /> PENALTY , <br /> I OTHER <br /> OTHER f <br /> Sri 1�3 -S-1210bo <br /> Received by 'Date 'F`""+ Receipt No. Permit No. lssu nce Date Mailed Bred <br /> r` -. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 S OCKTON,CA 95201 <br />