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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY. 1' <br /> Application i5 hereby made to the San JoaquinLoca HealthDistrictfor mittoconstructand/ Ilthework hereic described.This application is <br /> made in compliance with San Joaquin.Coun dlnance No. 18 and a rules and r ations of the San Joaquin Local He trict. <br /> Exact Site Address <br /> • �° f} City/Townes - <br /> Owner's Name Phon <br /> City <br /> Ad d ress <br /> Contractor's Name Se#�� Business Phone , <br /> Contractor's Address �ffnergency Phone - <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yeses No <br /> J <br /> TYPE OF WORK (CHECK):' " NEW WELL 2�--'''DEEPEN ❑ RECONDITION❑ " DESTRUCTION'❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION®— PUMP REPAIR❑ + <br /> REPLACEMENT❑ ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Sefpage Pit <br /> Property Line,,ga Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ` 0 CABLE TOOL Dia. of Well Excavation d �� <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Ilia- of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION a 11 GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ya, ROTARY Type of Grout v <br /> ❑ DISPOSAL_ ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor457 <br /> Type of Pump XH.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 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 forwhich this <br /> permit is issued, I shall emplo p on <br /> jes subct to workman's compensation laws of California." <br /> Ill call for a Grout I rior gro ting and a final inspection. <br /> Signed X <br /> Title: G- r. ^^^ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 0 3- <br /> Date ;— <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Pha e! Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> Fee Is Due:-❑ ANNUALLY °"❑"PER UNIT ❑ PER SITE `❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEBy July 31 <br /> - BASE EXPLANATION BILLING , REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE • REMITTED AMOUNT <br /> FEE <br /> r LESS <br /> PRORATION t <br /> PLUS I <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> 16, <br /> Received by <br /> D to Receipt N Permit No. Issuance Date Mailed_ Delivered G+4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2099_` �STOCKTONCA 95201 <br />