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Applications Will Be Processed When SubmittedProperly <br /> APPLICATION . <br /> MEIN (For Non-Transferable, Revocable, Suspendable) PUMP&WELLENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> ATE) <br /> Application is hereby madetothe SanJoaquin Local Health District for apermit toconstruct and/or install the work herein described.This application is <br /> made in compliance with S oatq to Gognty Ordi No. 1862 and t e ides and regulations of the San�Joaquin Local Health District. <br /> C ity/Town I <br /> Exact Site Address <br /> I A4. <br /> - Phone <br /> Owner's Name City f <br /> Address _ <br /> Contractor's Name <br /> License# '� Business Phone <br /> ? Contractor's AddressLJ 4 a '" Emergency Phone r" <br /> i <br /> —_I� NO 0 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLWD? Yes .� <br /> TYPE OF WORK (CHECK): NEW WELL Cl DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT C�� OTHER 13 PUMP INSTALLATION 13PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: S Iptic TankjSewer Lines ® Pit Privy <br /> ''• Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> k, ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> F ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal A <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> { <br /> 1-1OTHER Other Information <br /> ❑ DISPOSAL �� <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor . <br /> H.P. <br /> Type of Pump i <br /> PUMP REPLACEMENT: I ❑ State Work Done ' <br /> PUMP REPAIR: ❑ State Work Done <br /> Well Diameter Approximate Depth r <br /> DESTRUCTION OF WELL: r^ <br /> ` Des ribe Material and Pr dure � r <br /> r, C <br /> `,-� a <br /> I hereby certify that l have prepared this appl' ation and that the work will be ne in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. S <br /> }tome owner or.licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> f Contractor's hiring or sub-contracting signature certifies the following:"!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 <br /> , w I cal �r,a Gr t Inspec on prior to gr ting.and a sinal inspection. <br /> I� ► 110, Title: Date: <br /> F. Signe I� (Draw Plot Plan on Reverse Side) <br /> fJ FOR PAR ENT U ONLY <br /> PHASE IDate. <br /> Application Accepted By <br /> Additional Comments: Iy <br /> r <br /> Phase <br /> NI Fina! Inspection <br /> 11 Grout Inspection <br /> • Inspection By Date <br /> Inspection By Date <br /> j By <br /> Fee Is Due: ❑ ANNUAIXY ❑ PER UNIT PER SITE ❑ EACH ❑ January} &Received 8y January 31 July 1 8 RecelvREMITUty 31 <br /> I" BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE FXPLANATI N DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> I <br /> PENALTY <br /> OTHER , <br /> OTHER II <br /> �r <br /> Received by j Date <br /> Receipt No. Permit No. I suanc 'Date'' Mailed Delivered -. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.HAZELTON AVE.,P.O.Box•2009 sTOCK70N,CA 95201 <br /> II <br />