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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable). PUMP&WELL <br /> �. ENVIRONMENTAL HEALTH PERMIT <br /> s <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District'or a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San J aq oun Ordinance No. 1862 and the rules and regulations of the San in yLocal Health District. <br /> Exact Site Address O3 w City/Town <br /> fir v- . <br /> Owner's Name * Phone <br /> city <br /> Address - <br /> Contractor's Name License#'! Business Phone <br /> r, <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❑ DEEP N RECONDITION❑ ' DESTRUCTION❑ 4" <br /> WELL CHLORINATION 13 WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ =' <br /> REPLACEMENT❑.ase <br /> DISTANCE TO NEAREST: Se_ptic 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 't TYPE OF WELL <br /> I ❑ INDUSTRIAL ;❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia" of Well Casing I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal S <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ' <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 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 /> 16 <br /> DESTRUCTION OF WELL: Well Diameter 7, Approximate Dept <br /> ribe Material and Pro edur <br /> ��.. <br /> 1 hereby certify that I have prepared AS ap"pli n and that he work will be done in accordance with San Joaquin Count <br /> ordinances, state laws, and rules and regulations of,the San Joaquin Local Health District. <br /> '- <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 I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X _ Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> APP P YHAS Application Accepted B -"`�`�: Date <br /> Additional Comments: <br /> Phase II prout Inspection Phase 111 Final Inspection <br /> Inspection By Date t Inspection By Date <br /> Fee'ls Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> tBILLING, REMITTANCE � $ AMOUNT DUE CHECKED <br /> BASE 'EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> ' FEE <br /> t W <br /> LESS _2 <br /> PRORATION 't <br /> PLUS 1 i. :- <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ <br /> 7/37 1a C- l <br /> Received b - Date Receipt No.. - Permit No: - Issuance ate Mailed - Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA SS201 <br />