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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F6R OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> f PUMP&WELL i <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> I WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) � <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 w'th Snan Joaquin County Ordinance No, 1862 and the rules and regulations of the San Joaquin Local- <br /> / <br /> Health District. <br /> Exact Site AddressCity/Town _ _7tew� <br /> Owner's Name Phoned r <br /> Address City - <br /> Contractor's Name <br /> ie -ri,t/llc <br /> Contractor's Address i'YZG, 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 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> Q INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ 170MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 0 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ I61 <br /> RRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Install d By: <br /> PUMP INSTALLATION: Contractor <br /> €� Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work bone G, �- <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> j I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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 orsub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for of ut Inspection prior to grouting and a final inspection. <br /> f , <br /> Signed X - �— — Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FORD PARTME T USE ONLY <br /> I PHASE I <br /> Application Accepted By � Date <br /> Additional Comments: <br /> I Phase I Grout Inspection h se I I Final Inspection s� <br /> Inspection By Date Inspection By CR Date � sn <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 $Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f OTHER <br /> Ll <br /> ; Received by Date Receipt No, Permit No. Issuance Date Maited Delivered <br /> '41 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCKTON,CA 95201 <br />