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Applications Will Be Processed When Submitted Properlycompletea.tiesure io algn Ine„t,Nya.....• <br /> FOp''' FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) pUMp&WELL <br /> t <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 4r <br /> made in compliance with San Joaquin Count di rice o. 18F2 and a-rules and regulations of the San J uin Local H Ith District. <br /> Exact Site Address / !' City/Town <br /> r <br /> Owner's Name Phone• — � <br /> Address City f <br /> Contractor's Name <br /> �J" �/ License Business Phone l <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 WELL®--' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL. ABANDONMENT 13OTHER 11PUMP INSTALLATION PUMP REPAIR❑ ` <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank— Sewer Lines Pit Privy <br /> Sewage Disposal Field 6f/Seepage Pit ' Other <br /> Property Li Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑,�,, �IINDUSTRIAL ® CA�BLE TOOL Dia. of Well Excavation <br /> U+yDND�OMESTIC/PRIVATE Id1-DHILLED Dia. of Well Casing <br /> 0,•,,�DOMESTIC/PUBLIC - 13 DRIVEN Gauge of Casing <br /> VKRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br />` 0 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> E] GEOPHYSICAL Sure Seal fnsWy: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpH'P� O <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 /> 1 Hereby certify that l 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 /> Homeowner 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I vAttXall for a Grout Inspection prior to grouting and a final inspection. l <br /> d X{�~ le. Dater <br /> (Draw Plot Plan on Revers ide} <br /> Signe <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _D d <br /> Application Accepted By— <br /> Additional <br /> y Date <br /> Additional Comments: <br /> Plias li out Inspection II Fin spettion d <br /> t7 Inspection By' Date <br /> Inspection By Date Zy <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT y� PER SITE ❑ EACH ❑ January 1 &Received By January ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE t� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER /tel <br /> OTHER fL�/ <br /> Received by Date Receipt No, Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />