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t1l"jons Will Be Pero a se&� tren Submitted Properly Completed. Be Sure To Sign The Application. <br /> FGR OFFICE USE: AUG5 ��� APPLI'CATION <br /> U 1� (Foojr INIon-Transferable, Revocable, Suspendable) <br /> t iC)P.QIJIN � VVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> SRS �y p1STR <br /> (COMPLETE IN TRIPLICATEHEPIL�' WATER QUALITY r, <br /> t 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 /> 1 made in compliance ith San Joaquin County Ordinance No. 1862 and the rules and regulations of the San�J�°aquin Local Health District. it <br /> Exact Site Address U l City/Town <br /> Owner's Name 0 [f'i ( Phone <br /> Address els City r <br /> Contractor's Name 1ZN' � U License# usiness Phone.�p , 7 <br /> Contractor's Address c n SjQso fes Ar Emergency Phone j —� <br /> x <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No !, <br /> TYPE OF WORK (CHECK): NEW WELL 0 DEEPEN ❑ RECONDITION❑ :DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION-0 PUMP REPAIR <br /> REPLACEMENT❑ <br /> i` DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> l Property Line Private Domestic Well Public Domestic Well r <br /> INTENDED USE TYPE OF WELL <br /> 13 INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation <br /> KDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Cs <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Ip� <br /> El GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 1 <br /> PUMP REPLACEMENT: ❑ State Work Done $f <br /> k PUMP REPAIR: T State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I <br /> 6 Describe Material and Procedure . <br /> 1 � <br /> f' 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 /> I Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 a for a Grout In ctton p ' r to go ng and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> i <br /> FOR EPARTM NT USE ONLY ' <br /> i` PHASEI <br /> Application Accepted By X Date 2��G <br /> Additional Comments: <br /> Phase II Grout Inspection Phase ill Final Inspection = <br /> Inspection By Date - Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ER SITE ❑ EACH ❑ January 1 &Received By January 1 n 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> l AMOUNT <br /> fEE _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> ii PENALTY i <br /> OTHER l <br /> OTHER <br /> _ C�R�ceived by'. Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES— 1601 E.HAZELTON AVE.,P.O.Box 2009—.5TOCKTON,CA 95201 <br />