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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> OFFICE USE. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) .� <br /> WATER QUALITY <br /> AppliCatioriisherebymadetotheSanJoaquinLocall-fealthDistrictforapermittoconstructand/orinstallTheworkhereindescribed.Thisa application made in compliance h gan Joaquin Cou�jAn Ordirglue No. 18q and the r es and regulations of the San <br /> Exact Site Address �" a PP tlon is <br /> quip offal Health District. <br /> Owner's Name City/Town <br /> ` Address Phone <br /> Contractor's Name City <br /> Contractor's Address �L� License#j/ 3 Business Phone, <br /> + Is Certificate of Workman's Compensation Insurance on File With SJLHDmergYesy Phone 3 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ No d <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ RECONDITION❑ DESTRUCTION❑ I� <br /> REPLACEMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRI� <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field R <br /> Property Line Cesspaol/Seepage Pit Private Domestic WOther <br /> Well INTENDED USE Public Well <br /> ❑ INDUSTRIALTYPE OF WELL <br /> 0 CABLE TOOL _ Dia. of Well Excavation <br /> ®'DOMESTIC/PRIVATE" <br /> ❑ DOMESTIC/PUBLIC ❑ DRILLED Dia, of Well Casing <br /> El IRRIGATION 11 DRIVEN Gauge of Casing <br /> ❑ CATHODIC PROTECTION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ DISPOSAL — 13 ROTARY Type of Grout <br /> ❑ GEOPHYSICAL OTHER Other Information \ <br /> PUMP INSTALLATION: ' Surface Seal Installed By: <br /> Contractor ` <br /> PUMP REPLACEMENT; 'TYPe of Pump <br /> State Work Done H.P. <br /> ❑ — <br /> PUMP REPAIR: aState Work Done 9 f <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <br /> I hereby certify that I have prepared this appiication and that the work will be done in accordance with San Joaquin County 1t <br /> ordinances, state taws, 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 theperformanceof 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: y I <br /> permit is issued, I shall employ persons subject to workman's compensationlawsof California."rmance of the work forwhich this <br /> I wall fo a Grout In ction prior to gr ting and a final inspection. <br /> Signed X , <br /> �1d lot Title: <br /> J)yeC�w PPlan on Rever Side) Date: o� <br /> PHASE t FOR DEPARTMENT USE ONLY ' <br /> Application Accepted By <br /> Additional Comments: -a-`R Date <br /> Phase 11 Grout Inspection <br /> Inspection Bye ` Phase ill final Inspection <br /> Date Inspection By_- <br /> Date ,�j t h►L5� <br /> fee Is Due: ❑ ANNUALLY PER UNIT <br /> ❑ PER SITE ❑ EACH ❑ January 1 &RJanuary 31 eceived By Ja <br /> _ El July 1 &Receivetl By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> e <br /> OTHER <br /> Received oy Date - <br /> Receipt No. Permit No. Issuance Data <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered y� / <br /> 1607 E.HAZEL70N AVE_on <br />