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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 /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> (COMPLETE IN TRIPLICATE)., '"e-ll WATER QUALITY <br /> 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 wit San Joaquin County Cf! wn <br /> 0 nancQ No. 1 and the rules and gulations San Joaquin Local Health District. <br /> Exact Site Address <br /> ./ '� <br /> Owner's Name— Phone <br /> f <br /> Address J <br /> Contractor's Name nse usiness Phone n ' <br /> Contractor's Address3� Oy ency Phone _6Y, W*' F <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL�EEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ i OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Z Pit Privy <br /> Sewage Disposal Field yel�dd Cesspool/Seepage Pit Other I <br /> Property Line/fJyPrivate Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL rr <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation_ <br /> M UVMESTIC/PRIVATE ❑ DRILLED,11 Dia. of Well Casing �! <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION C3'1'-i0 ARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> `Jr� <br /> ❑ GEOPHYSICALSurface Seal Installed By <br /> ti- <br /> p @ <br /> UMP INSTALLATION: Contractor t'v <br /> `fype of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP,REPAIR: ❑ State Work-Done t '� <br /> 1-. 1, <br /> DESTRUCTION OF WELL: Well Diameter g i 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 /> d Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 t <br /> s permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will coWor a G ut Inspection prior to grouting d inal inspection. { <br /> t <br /> Signed X Title: _ �� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> s PHASE I <br /> 111 � <br /> Application Accepted By Date � l) <br /> Additional Comments: <br /> hase II Grout I spection]]^^�� Phas III Final Inspection I <br /> Inspection By (Date � Inspection By �(J .,Date " <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ,❑ J_u1y I &Received By July 31 I <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE 5 i N U E ' <br /> DATE DATE REMITTED _ AMOUN�TDUE` 3CHECKED <br /> AMOUNT <br /> x <br /> FEE '�b f .' - <br /> } LESS :r+ f} t <br /> r PRORATION _ <br /> PLUS <br /> PENALTY ' <br /> 1 OTHER <br /> OTHERC�y 5q <br /> o <br /> x <br /> ed <br /> ' RE;ceived by Date _ Receipt No Permit No � Issuance Date MaiSed Delivered- / <br /> >APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 STOCKTONA 95201 # <br />