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TheApplICallOn. <br /> B Applications Will Be Processed When Submitted Properly Completed. Be SureToSign <br /> r FOR OFFICE USE: - _ APPLICATION o <br /> r (FGr.Non-rt"ranslerable, Revocable, Suspendable) 1r/ PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> - <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 Joaquin County Ordinance No. 1 12 and the ru sand regulations of the San'SC ou <br /> Joaquin c Health District. <br /> Exact Site Address __,Vo City/Town <br /> Phone <br /> Owner's Name <br /> Address o S. me— � 419 / V4, City <br /> Contractor's Name �`� License#.�7�4O�G7 Business Phone <br /> Contractor's Address 0 k `� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> / <br /> TYPE OF WORK (CHECK): NEW WELL❑ ❑ RECONDITION❑ DO ❑ <br /> ❑ OTHER PUMP INSTALLATION ❑ PUMP REPAIRM <br /> WELL CHLORINATION [3 WELL ABANDONMENT <br /> ti <br /> l REPLACEMENT❑ <br /> E DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy p� <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �l <br /> i Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ElDOMESTIC/PRIVATE ❑ 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 Surface Seal Installed By: <br /> C <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump c <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 2� State Work Done _ <br /> I.-ILL •F <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r - <br /> I will 1 for Grout s ec ' prior to grouting and final inspe & n• - <br /> Signed X <br /> Title: �. Date: tg <br /> (Draw Plot.Pian on everse Side) <br /> qFOREPARTMENT USE ONLY <br /> PHASE I �� <br /> Date <br /> FApplication Accepted By <br /> Additional Comments: <br /> r Phase 11 Grout Inspection Pplase III Final Inspectio �Z <br /> 1 <br /> Inspection 8y <br /> Date lnspection,By Date <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recei By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> T - � <br /> LESS' <br /> PRONATION <br /> PLUS <br /> PENALTY <br /> r OTHER <br /> OTHER <br /> Received by20 <br /> Dae Receipt No. Permit No .-.. Issuance Date Mailed Delivered <br /> . - <br /> APPLICANT—RETURN ALL COPIES T0:-' -ENVIRONMENTAL HEALTH PERMIT/SERVICEs "'�""1601 E..HAZELTON AYE:,`P.0.8oK 2094 _STOTOCAs <br />