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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION I <br /> (For Non-Transferable, Revocable, 5uspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT . <br /> COMPLETE IN TRIPLICATE WATER QUALITY , <br /> ( ) k <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.Thisapplicationis f <br /> made in compliance with San-Joa_quin,CC. nntty�O,rdinance No. 186 an the rules and regulations of the San Joaquin Local Health District. <br /> Cit <br /> Exact Site Address r '� �f C - y <br /> = __ C � /Town <br /> Owner's Name Phone <br /> Address P City <br /> Contractor's Name License 43 Business Phone <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 ABANDONMENT ❑ OTHER 11 ' PUMP INSTALLATION 6_ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other l <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL. <br /> ❑ IN TRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <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 Donef, <br /> - F <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 Z <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." h <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work iorwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c r Grout Insp ction 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 /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout inspection II Final Inspection <br /> Inspection By Date Inspection By Date a <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> REMIT <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 /> -Received by- Date Receipt No. Permit No, Issuance Date Mailed Delivered - <br /> t - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />