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FOR OFFICE USE; ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign Application. <br /> ' <br /> APPLICATION <br /> (Far Non-Transferable, Revocable,'Suspendable) <br /> 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 with Sant oaquin County O finance No. 1862 and the rules and regulations of the San aquin Local Health District. <br /> Exact Site Address ' ,� <br /> City/1 I own - 1-IfaaL4, <br /> Owner's Name �rrw: a.. <br /> Phone <br /> Address 1 "..r a . ... .9 <br /> ",� ,r: .. .,. . , , .,.,• ... x ; <br /> Contractor's Name Y '` 1 ' ' City License# _ <br /> Contractor's Addres i"tc Business Phone <br /> n . ;Emergency Phone - . <br /> Is Certificate of Workman's Compensation I:nn,,tlsurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK):" NEW WELL} DEEPEN ❑ — No <br /> WELL CHLORINATION ❑ WELL ABA'N`DONMENT ❑ RECONDITION DESTRUC710N❑ <br /> REPLACEMENT 13 OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> DISTANCE TO NEAREST; Septic Tank I .�.._ y <br /> ) Cesspool Sewer Lines <br /> Sewage Pit Privy <br /> Property Line,/,_O—_f4_ <br /> Disposal Field l Seepage Pit Other <br /> ly -- (� <br /> Private Domestic Wel r <br /> INTENDED USE 'Public Domestic Well ,.-�--- <br /> TYPE OF WELLI <br /> EJ INDUSTRIAL - LABLE TOOL <br /> ❑ DOMESTIC/PRIVATE 1 Dia. of Well Excavation <br /> ❑ DRILLED . pia. of Well Casing s ��_ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> Gauge of'Casingi IRRIGATION uj❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Ey <br /> ❑ DISPOSAL Type of Grout <br /> O <br /> T ❑ THER <br /> GEOPHYSICAL Other Information <br /> ❑ - <br /> Surface Seal Installed By: 01 424e <br /> PUMP INSTALLATION: - Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: H.P. <br /> State Work Done i <br /> PUMP REPAIR:" ❑ State Work Done I <br /> DESTRUCTION OF.WELL- W;WeR 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 f <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 for which this <br /> permit is issued, I shall empl y 1sons subject to workman's compensation laws of California. <br /> I I or Gro Insp r to grouting and a final inspection. - <br /> Signed <br /> Title:._ nc __ Date: <br /> (Draw Plot Plan on Reve Side) 4r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE t <br /> Appiication Accepted By 1 _ r <br /> Additional Comments: '► Date t <br /> Phase II Grout Inspection <br /> Inspection By. <br /> - ' I Final Inspection I ` <br /> x ;Date Inspecto Date <br /> i <br /> } Fee.'fS DUB; ❑ ANNUALLY '❑ AER U_ NIT "" '❑ PER SITE - <br /> ' ❑ EACH ❑ Januar 1 & eceived By January 3t ` ` <br /> ❑'July 1 &Receided.By July 31 <br /> . <br /> BASF" 'EXPLANATION BILLING- .- .:_ REMITTANCE $ _ `REMIT <br /> 1 DATE DATE REMITTEp AMOUNT DUE CHECKED <br /> FEE`^ , <br /> AMOUNT I <br /> LESSJ. <br /> PRORATION -r } <br /> PLUS 1 <br /> PENALTY <br /> OTHER <br /> E � <br /> F OTHER . ..� �..� ..r. <br /> 1. Received by : Qate.. , b.-- <br /> Receipt No. Permit No. - issuance-Date <br /> APPLICANT—RETURN ALL COPIES TO: E - - Mailed Delivered <br /> ENVIRONMENTAL HEALTH PERMITISERVICES 1$01 E.HAZELTON AVE•,P.O.Box 2009 STOGKTON,CA 95201 !'• <br /> . <br />