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ns Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> Y (For Non-Transferable, Revocable,Suspendable) I <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT U <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY N <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or installthe work herein described.This application is <br /> made in compliance with San Joaquin County O�rkdinance a. 1 62nd the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address F" o Z3 City/Town 'F 0 }T <br /> Owner's Name <br /> L: �itl $S Phone 'I : <br /> Address �.' ♦ City h <br /> Contractor's Name N v t License#335',Z,; Business Phone <br /> Contractor's Address e)10 y Nit C,IEmergency Phone �_' 8 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X -- No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION it PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit An' Other <br /> i r <br /> Property Line gift, Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL N <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ' <br /> 13DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ' s <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal . <br /> ❑ CATHODIC PROTECTION M ROTARY Type of Grout -r-. ' <br /> ❑ DISPOSAL ❑BOTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor_. Z +frhF. t J <br /> !' Type of Pump ;t H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done l�Fii } ^1 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f ' <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 /> 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 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." f <br /> I will call for a�Girout Inspection prior to grouting and a final inspection. ; <br /> ' Signed X <br /> '; .. � Yt'i Title: �,` ,.;s-r 5 rr" Date: " <br /> (Draw Plot Plan on Reverse Si } <br /> E <br /> FOR DEP RTMENT USE ONLY <br /> PHASE I _ <br /> Date <br /> Application Accepted By- <br /> Additional <br /> y Additional Comments: ' <br /> Phase II Grout Inspection Phase ill Final Inspection <br /> Inspection By Datee Inspection By Date <br /> Fee IS Due: 11 ANNUALLY ❑ PER UNIT Ly PER SITE ElEACH ElJanuary 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BSLLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE wr <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> b <br /> Received by Dae Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZ£LTON AVE.,P.O.Box 2009 STOCKON;'CA 95201 _ <br />