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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR,aFFICE USE, 1. APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) t <br /> Lra Ce n PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 4 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/orinstallthework herein described.This application is f <br /> made in compliance with San Joaquin County Ordinance No.1862 nd the rules and regul ions of the San Joaq V-oval Health District. <br /> Exact Site Address '� . City/Town <br /> Owner's Name 7po'rt b Phone <br /> Address City <br /> — <br /> Contractor's Name 2 License# Business Phone42 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes No ` <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION UMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer.Lines Pit Privy <br /> Sewage Disposal Field t" Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well —'Public Domestic Well i <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑-CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 'PJ 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 <br /> ❑ DISPOSAL ElOTHER Other Information -C <br /> El GEOPHYSICAL Surface"Seal Installed By: <br /> PUMP INSTALLATION: Contractor e <br /> Type of Pump j �+ H'.P, 3 r►l <br /> PUMP REf_t49 NT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done x°` f1 <br /> DESTRUCTION OF WELL: Well Diameter m Approximate 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." i <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 /> } <br /> I ill call for a Grout lnspe io pri outing and a final inspection. <br /> Signed 11 Title: Date: x, <br /> (Draw Plo Plan on Reverse'Side) <br /> FOR DEPARTMENT USE ONLY <br /> l PHASE I * .{ <br /> -5 <br /> Application Accepted BrDat 4' <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <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 /> " BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> I FEE <br /> LESS 1 <br /> PRORATION <br /> PLUS yJ` <br /> PENALTY 17 <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No _Permit No Issuance Date Ma'sled Delivered ` <br /> APPLICANT—RETURN ALL'GOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �` _ _1601 E HAZELTON AVE.,P.D:Box 2909 "STOCKTON;,GA 95 � <br /> — .. .... <br />