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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) <br /> PUMP&WELL 1 <br /> ENVIRONMENTAL HEALTH PORMIT-' <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 wit San Joaquin County Ordinanc No. 186 and the rules and re ulations of the San Joaquin ocal Health District. �} <br /> Exact Site Address 1 g City/Town �f16n►r � .4 ,[ ]�s`.��- <br /> Owner's NamePhone - <br /> Address City <br /> Contractor's Name _ifiA - License#&?,f 11V Business Phone <br /> Contractor's Address Emergency Phone ` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ j <br /> REPLACEMENT❑ J <br /> f <br /> DISTANCE TO NEAREST: Septic Tank �J/�L) Sewer Lines_i��1-t Pit Privy (2—� S <br /> Sewage Disposal field/0_DI Cesspool/Seepage Pit Other <br /> Property Linem Private Domestic Well SD Public Domestic Well I, <br /> INTENDED USE TYPE OF WELL r. <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation rt <br /> i DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing e_1A jL s� -� <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> t ❑ DISPOSAL ❑ OTHER Other Information <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 5 <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 /> Home owner 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 /> t permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wit II for Gr It I p ction r to grouting and a final inspection. <br /> / I <br /> Signed X Title: c Date: r? a <br /> (Draw Plot Plan on Reverse e) <br /> I FOR DEPART NT USE ONLY <br /> PHASE <br /> Application Accepted By Date Q / <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> 4 Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT '�KIPER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> R MIT <br /> RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i DATE DATE REMITTED AM T <br /> I4 <br /> # FEE <br /> LESS <br /> PRORATION <br /> PLUS J <br /> PENALTY <br /> OTHER <br /> ]6 ' <br /> OTHER <br /> 7C <br /> I_ <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOM5201 <br />