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r'r'•••'Qrvns wnlBe Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE; - <br /> APPLICATION _on. <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH kRMIT <br /> (COMPLETE IN TRIPLICATE) PUMP&WELL <br /> Application is hereby made to the San Joaquin Local Health District WATER QUALITY <br /> made in e Address with.4n Joaquin C fora permittoconstruct and/or install thework herein described.This application ' <br /> made Site Address q tY Ordinance . 1 2 and the rules and regulations of the San Joa i I <br /> Exact <br /> /i I s <br /> Owner's Name Local. District, <br /> Address City/Town <br /> 7 Contractor's Name Phone <br /> Y <br /> fContractor's Address License City <br /> . Business Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD?Emergency Phone r <br /> r TYPE OF WORK {CHECK): NEW WELL❑ Yes No _ <br /> WELLCHLORINATIONFWK (CH ❑ DEEPEN ❑ RECONDITION I <br /> REPLACEMENT 11 WELL ABANDONMENT ❑ OTHER ❑ DESTRUCTION❑ <br /> DISTANCE TO NEAREST; PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> Septic Tank C <br /> Sewage Disposal Field Sewer Lines t <br /> Pit Privy <br /> Property Line --------� CessPOOI/Seepage Pit <br /> INTENDED USE Private Domestic Well - Other <br /> C1INDUSTRIAL <br /> TYPE OF WELL � Public Domestic Well <br /> El C <br /> 92-15—OMESTIC/PRIVATE BLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIClPUBLIC DRILLED `�+ spG>�'� <br /> ❑ DRIVEN Dia. of Well Casing <br /> ❑ IRRIGATION <br /> � GRAVEL PACK Gauge of Casing <br /> ❑ CATHODIC PROTECTION Depth of Grout Seal <br /> ❑ DISPOSAL ❑ ROTARY <br /> ❑ GEOPHYSICAL <br /> ❑ OTHER Type of Grout <br /> Other Information <br /> PUMP INSTALLATION: Surface Seal Installed By: <br /> Contractor <br /> PUMP REPLACEMENT: Type of Pump <br /> ❑ State Work Done H. e <br /> PUMP REPAIR; N <br /> DESTRUCTION OF WELL: <br /> State Work Done <br /> Well Diameter �1 <br /> Describe Material and Procedure Approximate Depth <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. } <br /> Home owner ar licensed agent's signature certifies the following. quin County <br /> i5 issued, ! shall not employ an 9="I certify that in the performance of the work for which this permit <br /> P Y y person in such manner as to become subject to workman's compensation laws Of California," <br /> Contractor's hiring orsub-contracting signature certifies the following., <br /> permit is issued, I shall employ 9 "I certify that in the performance of the work forwhich this <br /> P y persons subject to workman's compensation laws of California." <br /> Signed X Iw' IIf raGr utl <br /> pection prior to grouting and a final inspection. <br /> Title: <br /> (Draw Plot Plan on Reverse Ide) Al Date; <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: <br /> Date <br /> Ph sell Grout Inspection Date C _ <br /> Inspection ey � �� Phase III Final Inspection <br /> Inspection By i <br /> Fee Is Due: ❑ ANNUAL Lr Lv�II Orly{ ,�p/ Date <br /> ❑ PER UNIT ❑ PER SITE [fj <br /> BASE <br /> EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received B <br /> EXPLANATION BILLING REMITTANCE Y July 31 <br /> DATE DATE UNTDUE$ AMOREMIT <br /> FEE � REMITTED CHECKED <br /> LESS <br /> AMOUNT <br /> (� <br /> PRORATION G1' <br /> PLUS < <br /> PENALTY <br /> OTHER <br /> OTHER <br /> SS :} <br /> Received by Date V <br /> APPLICANT—R Receipt No. Permit No. <br /> —RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date <br /> Mailed Delivered <br /> 1601 E.HAZELTON AVE an n__--- <br />