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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 /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSanJoa u`inLoca a `Di tri" ra rmiiitt��° cta rl stall the work herein described.This application is <br /> made in compliance with San Joaquin ��rhty�Ol �e do.1 6 a dYtic-�-fuh5s,46 reg la loVof the San Juin L cal Health District. <br /> Exact Site Address �� City/TownJr <br /> Owner's Name L Phone S r <br /> Address of/— <br /> City <br /> ' <br /> Contractor's Name License���5 Business Phone_ �� '.Z OZ <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 ❑ WELL A13ANOONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 11 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank lllaek� Sewer Lines Pit Privy l��r <br /> Sewage Disposal Field Cesspool/Seepage Pit Other— <br /> Property Line. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ere <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing /9 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal CJS <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Instal d By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_ _._.. H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> D-escribe 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:"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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed XTitle: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE V <br /> Application Accepted By Date /3 . <br /> Additional Comments: <br /> h II Grout Inspection ase Ilf a I pection <br /> Inspection By r Date Q Inspection By <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 RFWTTANCE AMOUNT DUE CHECKED <br /> DATE DATE }REMITTED AMOUNT <br /> FEE y� <br /> LESS <br /> PRORATION <br /> PLUS —7� <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 72 <br /> Received by bate Receipt No. - Permit No. Issuance ate Mailed Delivered - <br /> - - APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMITlSERVICES _ + 1881 E.tIAZELTON AvC,P.D.Box 2009 S70CKTOM,-?NA <br /> r <br />