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. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WE[.!. <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 San Joaquin County Ordin nce No. 1862 and the rules and regulations of the San Joa u'n Local Health District. <br /> Exact Site Address f� �E' City/Town <br /> Owner's Name i ti Phone <br /> Address City + <br /> c <br /> Contractor's Name Gt icense# Business Phone r e <br /> Contractor's Address ) Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No �J <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIOND <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAID <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy a <br /> Sewage Disposal Field Cesspool/Seepage Pit Other_-_ <br /> Property Line Private Domestic Well 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 PACKDepth of Grout Seal j <br /> El CATHODIC PROTECTION 13 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Otherrinformation <br /> ❑ GEOPHYSICAL i 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 Approximate Depth . <br /> Describe Material and Procedure <br /> a: <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 wil call for a Grout Inspee ion prior to grouting and a final inspection_ ' <br /> Signed X - - -- - - --- -_ -...Title- _ act r�� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> �FOR�DEPARTMENT USE ONLY` <br /> PHASE <br /> Application-Pccepted By °' -- Datalid <br /> Additional Comments: <br /> Phase II Grout Inspection P_ Final Inspection <br /> Inspection By Date Inspection By Date 3 <br /> i <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &ReceivedJanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT i <br /> BILLING REMITTANCE $ <br /> RASE BILLING DATE DATE REMITTED AMOUNT DUE CHECKED - <br /> AMOUNT <br /> FEE —6 1; <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> Received by - Date - Receipt No. Permit I 11suaAce Date Mailed De eyed - <br /> APPLICANT-RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 9520 <br />