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_ _ ►� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> OR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL � GQ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �T 73 © E, <br /> N <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is 0 <br /> made in compliance with San Joaquin County Ordinan e N 1862 and the ruIV and regulations of the San Joaquin Local Health District- <br /> Exact Site Address Gtj �_ _ City/Town 4' <br /> Owner's Name !✓ — "'•""�"��' Phone <br /> Address E City {�" <br /> s Contractor's Name License#,U T4 / Business Phone <br /> Contractor's Address c) Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD?. Yes L--� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION L3 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION t r PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage-Pit F Other 4 <br /> Property Line Private Domestic Well Public Domestic Well rM <br /> INTENDED USE TYPE OF WELL `� 3 <br /> !I. ❑ INDUSTRIAL «.+a + - ❑ CABLE TOOL Dia. of Well Excavation <br /> k` DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing `I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIGauge of CasinVEN _ <br /> g <br /> ❑ IRRIGATION ❑ GRAVEL PACK: Depth of Grout Seal t ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ; <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ �. <br /> GEOPHYSICAL <br /> • � 5urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor _ j <br /> i Type of Pump H.P. - ; <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> _ Describe Material and Procedure ti _ <br /> I hereby certify that I have prepared-this application and that the work will be done in accordance with San Joaquin County 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 cArtify thaPi`nthe performance of the work for which this per lt <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California"." M <br /> f <br /> Contractor's-hiring or sub-contracting signature certifies the fallowing:"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 wil call r a Grou s ection prior to grouting anp <br /> _d a final insection\ <br /> Signe ' <br /> Title: Date: i ` <br /> (Draw Plot Plan on Reverse Side} <br /> FOR DEPARTMENT USE QNL-Y a <br /> PHASE I <br /> Application Accepted By <br /> _ Dater__-J__C7 V <br /> F <br /> Additional Comments:-~ e <br /> •+`—Phase'II Grout Inspection '- Pha final Inspection F <br /> Inspection By Date '� '°" "��"_" ""'. <br /> Inspectron_B.y _ _Date <br /> s <br /> .Fee IS DUE: ❑ ANNUALLY - 11-PER-UNIT ❑ PER SITE ❑ EACH-rs'r+...0 January 1 &Received By January 31 ❑ July 1 8-Received�y July 31 <br /> BILLING RE 'err REMIT <br /> REMITTANCE <br /> BASEA' EXPLANATION <br /> $'*` _-AMOUNT DUE. C7-IECKED <br /> DATE DATE REMITTED, AMOUNT ; <br /> FEE r a <br /> A <br /> + LESS <br /> PRORATION `- - <br /> PLUS <br /> PENALTY <br /> OTHER 4 s <br /> t OTHER <br /> Received by Date Receipt No. _x. Perrn4t No. p��ryf/ Issuance Date -*Mailed ,r�Delivered <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES f `1601 E.HAZELTON AVE.,P.O.-eox 2OD9 STOC,(r O- CA <br /> 3/1nl r <br />