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Applications Wiii Be Processed When SubmittedProperly completea. Isesure ioaign PnnMIJJAF.MIW� <br /> FOR OFFt(f USE: APPLICATION ��tl <br /> (For Non-Transferable, Revocable, Suspendable) !/ <br /> PUMP&WELL , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with an J agJJia my Ordinance Imo.182 and the rules and regulations of the SanL�oc�a��t Distri t. <br /> Exact Site Address ,^✓ee z/T'✓ City/Town <br /> 4/ epl <br /> 7" <br /> Owner's Name ���~ �� Phone <br /> Address City Q <br /> L # <br /> � 3� Busines hone <br /> Contractor's Name �J 4 <br /> Contractor's Address <br /> e 'Emergency Phane i <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 ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION L PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> r Property.Line Private Domestic Well Public Domestic Well <br /> SINTENDED USE_ TYPE OF WELL I I -- - - — . `- <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> eIRRIGATION � � ❑ GRAVEL PACK Depth of"Grout Se <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 P _ <br /> PUMP REPLACEMENT:}/ 7-6tate Work Done <br /> PUMP REPAIR: ❑ State Work Dane . <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 0 <br /> F ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 ' ing or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> per ed, I shall a persons subject to workman's compensativ aws of California." <br /> will out In peclio prior to grouting and a line/ inspection <br /> �_ Title. Date: / <br /> Signed X — - _ - <br /> (Draw Plot Plan on Re e'rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,� to <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout nspection Phase 111 Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ElANNUALLY ❑ PER UNIT ElPER SITE ❑.EACH ❑ January 1 &Received By January 31 E] July 1 8 Received By July 31 - <br /> fREMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> a'7, 3 <br /> .i. <br /> Issua ce Dai Mailed Delivered <br /> Received by -Gate - Receipt No, Permit No. <br /> E APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STQCKTON,CA 95201 <br />