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FOR oFICE USE: Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, y� _ <br /> APPLICATION <br /> (For Non-Transferable, Revocable,`Suspendable) <br /> PUMP&WELL <br /> (COMPLETE IN TRIPLICATE <br /> ENVIRONMENTAL HEALTH'PERMIT �� <br /> WATER QUALITY <br /> I Application is hereby made tothe San Joaquin Local}-iealthDistrict fora permit toconstruct and/or in' <br /> stall the work herein described.This application is <br /> made in compliance with San Joaquin Count. Ordinance No. 1.8 2 and the rules and regulations Of the San Joaquin Local Health District. <br /> Exact Site Address , Gtr. <br />' City/Town � �,,.. .�,�, <br /> C Owner's Norrie 1 t C,b -• .*,;-$,. <br /> Address V c+�c Phone <br /> Contractor's Name �3 - rk # City _ <br /> Contractor's Address +,r ';..'� �. License# w �� �> <br /> Business Phone <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes t-l", <br /> TYPE OF WORK (CHECK}: NEW WELL❑ DEEPEN 11 No _ <br /> WELL CHLORINATION ❑ - WELL ABANDONMENT 11 OTHER <br /> � DESTRUCTION❑ <br /> REPLACEMENT 13OTHJ=R 11PUMP INSTALLATION ❑ PUMP REPAIR L& 10 <br /> DISTANCE TO NEAREST: Septic Tank (n <br /> Sewer Lines Pit Privy 1 <br /> ; <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Other <br /> p Y Private Domestic Well Public Domestic Well t �, <br /> INTENDED USE TYPE OF WELL <br /> El INDUSTRIAL TYPE <br /> TOOL <br /> ❑ Dia: of Well Excavation <br /> ❑ DOMESTIC/PRIVATE <br /> DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION <br /> ROTARY Type of Grout <br /> ❑ DISPOSAL- ❑ OTHER <br /> IJ GEOPHYSICAL Other Information <br /> SurfaceSeal Installed By,, <br /> PUMP INSTALLATION: Contractor <br /> PUMP REPLACEMENT: <br /> Type of Pump H P F <br /> ❑ State Work Done <br /> PUMP REPAIR: Ah <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local County Health District. ' -�-? <br /> f Home owner or licensed agent's signature certifies the following:g g g:"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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California," ' <br /> I will call tqr a Gt Inspection prior to grouting and a final-inspecti <br /> Signed X ,7 G�C.... Title: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase rout Inspection ,. h <br /> Inspection By 11 G �? Phis e 111 Final-Inspection <br /> ;Date s Inspection By r Date <br /> f _ , <br /> Feeds Dye: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑'-JanuaryVt&Received B +r <br /> y January 31 ❑ July 1 &Received By July 31 <br /> j <br /> BASET EXPLANATION BILLING REMITTANCE t, $ REMIT <br /> DATE DATEREMITTED AMOUNT DUE CHECKED <br /> S <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 4,- <br /> OTHER <br /> Received by Date Receipt No. <br /> P Permit No. Issuance Date - Mailed 4 Delivered �/a!e_!S//I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AYE.,P.O.Box Tens srnrrm. r..,�,,., r <br />