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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FQR QFMCE USE: APPLICATION <br /> (For Non-Transferable,Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> WATER QUALITY . .m..,.. •., <br /> (COMPLETE IN TRIPLICATE) T <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew ork herein described.This application is <br /> made in compliance with pan JoaquinCounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address_ .U/ r /fd -�/� City/Town <br /> IG'Tllt Phone <br /> Owner's Name S Z-'0 a� <br /> _ Address 1 r City :: _ <br /> �: 0, License#737/S-40- Business Phone <br /> Contractor's Name �L �auI CF, <br /> Contractor's Address .7, ` " Emergency Phone <br /> is Certificate of Workman's Compensation I�nsur �on File With SJLHD? Yes No r__ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ - RECONDITION❑ DESTRUCTION❑ (J�, <br /> I WELL CHLORINATION 13WELL ABANDONMENT 13 OTHER-❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> D r Sewer Lines �d Pit Privy <br /> k Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line ' Private Domestic Well Public Domestic Well <br /> TYPE OF WELL ►J <br /> ❑ IN US7RIALUSE 13CABLE TOOL Dia. of Well Excavation <br /> d <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ^^ s auge of Casing <br /> " ❑�ROTARY <br /> RIVEN G <br /> ' ❑-iRRIGATiQi�l�---. x-- <br /> t. C ��.D:epth.of-Grnlit'Seal❑ CATHODIC PROTECTION Type of Grout t t <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL <br /> Surface ySeall�i1 Med 8 <br /> PUMP INSTALLATION: Contractor } <br /> TypePum of H.P. <br /> P 3 � � I ( <br /> PUMP REPLACEMENT.i �•� ❑ State Work Done <br /> i <br /> PUMP REPAIR: 11State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate D2pth <br /> � 5 <br /> - Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will'" don Win acc"rtlatigpzwith San Joaquin County <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 Califdrnia." <br /> Contractor's'hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for whichthis <br /> I to workman's compensation lalvs of California." <br /> permit is issued, I shall employ persons subjec <br /> I will call fora Grout Insp ction prior to grouting and a final-inspection. <br /> Title: w Date: <br /> Signed X j <br /> (Draw Plot Plan on Reverse Side) j <br /> - <br /> 2 F.OR,ipEPAFITMENT_USE;ONLY <br /> :. u t <br /> PHASE <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> PlIese 11 Grout Inspection / Pas 111 Final Inspe on <br /> Date t�b Inspection By `Date 3 <br /> Inspection By t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑ January 1 6 Received By January 31 ❑ July 1 &ReceiveRdEBylTuly 37 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 4U r <br /> V a <br /> FEE a � <br /> r H <br /> LESS $. ' <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ��Pi C; ra 9�' <br /> Issu nc Mailed Delivered <br /> Received by <br /> Date Receipt No. Permit No. D <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOCKTON,CA 95201 <br />