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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance weitthan oa Lill County Ordinance No. 1862 and t e r les and regulations of the San Jo UIn Local XaDistrict <br /> Site Address / ! ��y City/Town f ' l h �1 <br /> Owner's NameePhone <br /> Address / 5s City <br /> Contractor's Name Licensl7 Business Phone <br /> Contractor's Address gency Phone f <br /> Is Certificate of Workman's Compensation Insurance on File With S HD? Yes No —C, <br /> TYPE OF WORK (CHECK): NEW WELL 03"-DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION @--. PUMP REPAIR❑ <br /> REPLACEMENT❑ / J <br /> DISTANCE TO NEAREST: Septic Tank 15-0 Sewer Lines .. G Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line _ Private Domestic Well Public Domestic Well <br /> " <br /> INTENDED USE "" TYPE OF WELL I a. o <br /> Dia Well Excavation <br /> -�❑-CABL,E TOOL <br /> � r <br /> ❑ INDUSTRIAL '? . . h <br /> OMED- <br /> STI.0/PRIVATE ' "�'' - dla., W <br /> -"❑ FiILLED of. ell,Casin_ 9 <br /> 1:1DOMESTIC/PUBLIC,, �Y ' 11-DRIVEN Gauge ofi Casing '1� -- <br /> ❑-IRRIGATION.- ❑ GRAVEL PACK Depth of Grout Seal~� V <br /> ❑ CATHODIC PROTECTION 'ROTARY Type of Grout A ` <br /> © DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Inst ed By: in <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_--nR3�+ H,P. r. <br /> PUMP REPLACEMENT: ❑ State Work Done ` <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter -. Approximate Depth— <br /> : � <br /> Procedure 9+ J1 <br /> "-"'"Describe Material-and <br /> I hereby certify that I have prepared this application and that the wol will be done in'accordance with'San Joaquin County <br /> t� ordinances, state laws, and rules and,regu'latiens=of the.San Joaquin Local Health District. <br /> I, r Home owner or licensed agents signature certities thefo I wing:"I certify that in.the performance of the work forwhich 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 /> ja <br /> Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance f the work forwhich this <br /> permit is issued, I shall employ persons subject to work,man`s-or pen sat ion laws,of California." <br /> I will c for a Grout Inspection prior to gro t' .and a-liin_a1 inspection. fJ F <br /> Signed X �"'_ ,� .,;, - Title: r:+'�"�,!? ----y+- Date: <br /> i (Draw Plot Plan on Reverse Side) ° ;r <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> 1= .PHASE <br /> Application Accepted fay Date <br /> i <br /> AdditionahComments: <br /> Phase it Grout Inspection -Phase III Final Inspection <br /> Date Inspection By Date <br /> Inspection By � s ; <br /> \\ 6 <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER-UNIT ❑ PER SITE EACH ❑ January 1 8 Received 6y January 31 ' ❑ July 1 &Received By July 31 , <br /> REMIT <br /> KILLING REMITTANCE ` $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT I <br /> f <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS . <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> Receive by pat Receipt No- Permit No. Issua.ce_ate Mailed Delivered /'/� G <br /> APPLICANT—RETURN ALL:COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOI CA 95201 T <br />