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' Applications Will Be Processed When-Submitted Properly Completed. a SureTo <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f <br /> i <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> i <br /> inLocalHealthDistrictforapermittoconstructand/or installthe work herein described,This applicationis <br /> Application is hereby madetotheSanJoaqu <br /> made in compliance with San Joaquin County Ordinance No. iB62 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> i Exact Site Address ,D <br /> I Phone �Z <br /> Owner's Name <br /> City <br /> Address <br /> E <br /> Contractors Name License# 2V Business Phone <br /> Emergency Phone _p <br /> Contractor's Address a <br /> Is Certificate of WorVan's Compensation I,nnsuurrance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL W DEEPEN C1 OTHER RECONDITION <br /> ❑ ITI PUMP INSTALLATION ❑❑ PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <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 N <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation / <br /> DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing -�l✓+✓ <br /> 13DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ IRRIGATIONGRAVEL PACK Depth of Grout Seal <br /> 13CATHODIC PROTECTION ROTARY Type of Grout <br /> 13 DISPOSAL ❑ OTHER Other Information T_ <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 Done <br /> DESTRUCTION OF WELL: <br /> 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. <br /> Signed X <br /> Title: Date: <br /> (Dr Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY . <br /> FApplication <br /> Date. <br /> Accepked By <br /> l Comments: <br /> Pll�hse 11 Gr t Inspection P III Fina nspecl9 <br /> t Inspection B <br /> Date �"` Inspection By ate <br /> Fee IS DUe: ❑ ANNUALLY El PER UNIT ❑ PER SITE El EACH El January 1 &Received By January 31 ❑ July 1 &Received 6y July 31 <br /> REMIT <br /> 1 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> PATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PROHATION <br /> PLUS S <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �o (o3c 16c-)-_� � <br /> ate Receipt No. Permit Na. Issuance Date Mailed Delivered <br /> Received by <br /> 1401 E.HAZELTON AVE.,P.O.Box 2009 STOCt(TON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />