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Applications Will Be Processed WhenSubmittedProperlyeompletea. tiesure Toaign IneMJJP11%,0L1W-1. <br /> R OFFICE USE: x APPLICATION <br /> C C3✓�+�0 (For Nan-Transferable;Revocable, Suspendable) 9 <br /> --f--��, PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER,QUALITY ; <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install theworkherein described.This applicationis S <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin ocal ealth D' trict. <br /> Exact Site Address �� 2 � rr moi_ City/Town <br /> Owner's Name Phone <br /> Address '_� City _ ' <br /> ,License#� ;�Business Phone <br /> Contractor's Name �- . <br /> Contractor's Address 6� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on F _ile Wit SJLHD? Yes XNo <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ I <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ t <br /> :DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other I <br /> Property Line Private Domestic Well Public Domestic Well t } <br /> INTENDED USE TYPE OF WELL ' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br />` ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> PUMP INSTALLATION: Contractort'A", <br />{ off <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done P' <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 /> Ir <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." a <br /> I wil call for a Grout Inspection pr' t gr tit g and a final inspection. <br /> /'" <br /> Signed X �'�' isle: Date:. . <br /> (Draw Plot Ian on Reverse Side) <br /> i. <br /> FOR DEPARTMENT USE ONLY <br /> f PHASEI <br /> Application Accepted B �� Date Zl— 7 <br /> Additional Comments: <br /> Phase 11 Grout inspection P a e III F' al Inspection <br /> Inspection By Date Inspection By Date 12- " 2 <br /> - Fee Is'Due: ❑ ANNUALLY- ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> } REMIT <br /> BA5E EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE ('p <br /> 5• �y �a <br /> LESS U <br /> PRORATION <br /> PLUS - <br /> PENALTY = <br /> OTHER <br /> OTHER r <br /> -79 <br /> Received by Date Receipt No. Permit No Is nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONA VE.,P.O.Box 2009 STgCK D ,CA 261 - <br /> — rr <br />