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} <br /> �s/ Applications Will Be Processed When.Submitied Properly CampleieBeSure o Sign <br /> •"F1'}R OFFICE USE: APPLICATION� <br /> Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT _ <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> it to construct and/or described.This application is <br /> Application is hereby made to the San Joaquin Local Health District for a perm <br /> made in.compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin L Health District. <br /> Exact Site Address A City/Town <br /> � �- Phone <br /> Owner's Name <br /> - � City� ry <br /> Address 6� V <br /> Contractor's Name -" <br /> „. License#/ p ��` Business Phone O <br /> Contractor's Address Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes—�- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ' Sewer Lines Pit Privy <br /> Sewage Disposal Field -dF _ - -Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 13INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE C1 DRILLED <br /> 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 Instal d By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP-RE-P*tF( P State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> m <br /> Describe Material and Procedure <br /> +F>. <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 wililcall for a Grout Ins rf r t grouti g an final Inspetstion. <br /> t. <br /> itle: Date: <br /> Signed X <br /> (Draw Plot an on Reverse Side) <br /> FORD PART ENT USE ONLY <br /> . PHASE I Date a 8U <br /> Application Accepted By <br /> Additional Comments:• <br /> Phase R Grout Inspection phase fnal Inspection <br /> i <br /> Inspection By Date Inspection By Date <br /> F Fee IS Due: El ANNUALLY PER UNIT ❑ PER SITE EA ❑ Sanuary 1 &'Received By January 31 -WY{❑ July 1 &Received By July 31 <br /> REMIT <br /> t BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT .: <br /> FEE C <br /> LESS - <br /> PRORATION <br /> r <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> ------------ <br /> OTHER <br /> 1 Z 7M- <br /> Issuance Date Mailed Del;vered <br /> d <br /> Received by� '°�y,,,, Date Receipt No, - _ Permi No- �+ <br /> APPLICANT—RETURN ALL COPIESNVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 $TOCKTOKTON,-CA 95201 <br />