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ApplicationsWill Be Processed When Submitted Properly Completed:Be-Sun To Sign The Application. <br /> FOR OFFICE USE: APPLICATION _ <br /> V (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 for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San auin Count rdinance No. 186�and the rules and regulations of the San Joaqui cal Health ietrict. <br /> Exact Site Address �� /lf/tiL" na City/Town in!inf Ct_ 92 <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License#�� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensatio Insurance on File With SJLHD? Yes No �} <br /> TYPE OF WORK (CHECK): NEW WELLN DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> El CHLORINATION WELL ABANDONMENT 11 OTHER El PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 7 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation I <br /> DOMESTIC/PRIVATE P 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 Surfacp Seal I stalled By: 6_2,(�nn" 4 <br /> PUMP INSTALLATION: Contractor IC41 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done CNI. <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 /> Homeowner 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. e <br /> Signed X Title: Date: <br /> .(Draw Plot Plan on verse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Pha 11 rout Inspection Phase Ili Final,Inspection <br /> Inspection By CINC-0 Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 J <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE - CHECKED <br /> DATE DATE REMITTED AMOUNT ; <br /> FEE � <br /> { <br /> LESS <br /> PRORATION <br /> i <br /> PLUS - - - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> is <br /> Rec —�A-by-*k Date Receipt No. Permit No.. Issuan e Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES-- - 1607 E.HA1'ELTON AVE.,P.O.Bax 2009 STOCiSTON,CA 95201 <br />