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r ... .. <br /> Applications Will Be Processed When Submitted ProperlyCompleted. N <br /> �� USE: APPLICATION <br /> Fo <br /> a (For Non-Transferable,Revocable,5uspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ® WATER QUALITY <br /> + {COMPLETE IN TRIPLICATE} <br /> District fora permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Hee+th <br /> made in compliance with San Joaqu' ounty Or n(_,e No 862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Addres <br /> Phone <br /> Owner's NaITJe City <br /> Address B i es hone <br /> Contractor's Name License#�� <br /> Emergency Phone <br /> Contractor's Address <br /> f <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 /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE <br /> 1311 INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> X DOMESTIC/PRIVATE r Gauge of Casing <br /> 11DOMESTIC/PUBLIC El DRIVEN <br /> It ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> f <br /> 11 GEOPHYSICAL Surface Seal Installed By: 6- <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: t ❑.State Work Done <br /> PUMP REPAIR: # State Work Done , <br /> DESTRUCTION OF WELL: <br /> ,__ �.m Well Diameter —-" Approxima�De <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:"1 certify that in the performance of the work for which this permit <br /> H ti <br /> issued, 1 shall not employlany person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-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 wjPl call for a Grout Inspel tion prior to grouting and a final inspec n. <br /> w <br /> ` } Title: e. Date: <br /> 51 Signed X <br /> �j (Draw Plot Plan on Reverse Side) <br /> l t <br /> I FOR DEPARTMENT USE ONLY <br /> PHASE 1 Dated <br /> Application Accepted By <br /> F Additional Comments: <br /> PlFinal Inspection <br /> Phase ll Grout Inspection Date !� <br /> inspection By Date Inspection By <br /> r Fee Is DUB: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J 1 &Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> BILLING MITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEEy� v" <br /> I LESS f <br /> PRORATION i J <br /> € PLUS �g 1P• Aic ~' . <br /> PENALTY <br /> OTHER .' <br /> OTHER i <br /> Received by Date '� <br /> Receipt No. Permit No 4�u.re Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 57OCKTON,CA 95201 . <br /> '. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES _ _..+ <br />