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o. ApplicationsWill Be Processed When Submitted Properly Completed~Be Sure To Sign The Application. F <br /> FOR OFFICE USE: APPLICATION J <br /> s _ �11 (For Non-Transferable, Revocable,Suspendable)� -� <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL _ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is 6 <br /> made in compliance with San Joaquin Count Ordmanc o. 1862 and t e rules and regulations of the San quin Local Health District �.� <br /> . <br /> Exact Site Addressk City/Town <br /> Owner's Name94Phone <br /> Address City <br /> Contractor's Name / License Business Phone J � <br /> Contractor's Address �� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNo <br /> TYPE OF WORK (CHECK): NEW WELL X DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ TI <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tankr <br /> S ewer Lines�)- .4 -_ Pit Privy —^-- <br /> Sewage Disposal Meld f Cesspool/�eepage Pit Other —-� <br /> Property Lin e10 _ Private Domestic Well%52� of Public Domestic Well <br /> INTENDED USE 1 TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation A <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal r <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 /> DESTRUCTION OF WELL: Well Diameter <br /> I Approximate Depth <br /> # <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. s <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 1 <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 pers s subject to workman's compensation laws of California." i <br /> I will call for a Gr 1 I pecti r to grouting and a final inspection. 1 /' <br /> Signed X Title: C Date: _�T_QC{ �ry <br /> (Draw Plot Plan on Reverse S e) <br /> FOR DEPARTMENT USE ONLY I <br /> PHASEI <br /> p r <br /> Application Accepted By Date 1 -7q <br /> Additional Comments: <br /> Phase 11 Grout Inspection inal Inspection <br /> Inspection By Date Inspection B Date <br /> Fee Is lJe�❑ ANN ALLY PEA UNIT ❑ PEA SITE ❑ EACH ❑ Jan ary 1 &Received By January 31 0 July 1 &Received By July 31 !+ <br /> 4 SELLING REMITTANCE - $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> jI, DATE DATE REMITTED <br /> F AMOUNT E <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS p <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -11s10 1a 7 <br /> Received by - Date Receipt No. Permit No. Issuance Date Mailed belivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMP <br /> I ENTAL HEALT#iERM'T1SERYICES <br />_ ' - V 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95 � <br />