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Applications Will Be Processed When Submitted ProperlyCompleted BeSureTosign 1neAppncallon. <br /> FOR oFICE USE: APPLICATION <br /> 'S (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL .# <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is ' <br /> made in compliance with San Joaquin County Ordinance No. 1862 and th/q rules and regulations of the San qui Local Health District. } <br /> Exact Site Address ^� �Q�5'"o City/Town <br /> Phone <br /> Owner's Name <br /> AddressCity <br /> Contractor's Name License#. L__ Business Phone -�� �� f► <br /> Contractor's Address Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File fith SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTIO,N,❑ <br /> WELL CHLORINATION ❑ , WELL ABANDONMENT I] OTHER 13 PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer-Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well - <br /> INTENDED USE TYPE OF WELL ' <br /> ❑,..,,�IN STRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> UW60MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing . <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal .� <br /> ❑ CATHODIC PROTECTION ❑ ROTARY (v Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Qther Information <br /> 11 GEOPHYSICAL a1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 1 Type of Pump ' t H.P. <br /> El State Work Done <br /> " PUMP REPLACEMENT: � <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 San7whichthis <br /> nty= <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 fomitis issued, I shall not employ any person in such manner as to become subject to workman's compensation laa." <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 Califor'riia.'F y' _ <br /> ca a Grouts pection prior to grouting and a final inspection. <br /> I <br /> . Sig Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I" PHASE I <br /> Dat —� <br /> Application Accepted By j <br /> Additional Comments: <br /> s II Grout Inspection Ph se-ill-Fin-iii inspection� <br /> Inspection By <br /> Cil 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 /> h <br /> le" FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> OTHER <br /> Permit No. Is ance ate Mailed Delivered t <br /> Received by Date Receipt Na - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMWS_ERVICES 1601 E.HAZELTON AVE.,P.O.BOY 2009 5TOCKTON,CA-95201 <br />