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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FQR'OfFICE USE: n APPLICATION�p)•t�IrJ . 0 (For Non-Transierable, Revocable, Suspendable) <br /> l !� PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is her tiy,madetotheSa' Joaquin Local Health Districtfora permitto construct and/or install thework herein described.This application is <br /> :. made in compliance with San Joaquin County Ordinance No. 1862 and the ales and regulations of the San Joaquin Local Health Di rict. <br /> Exact Site Address 3 I�. Gtr Est.e `�liL City/Town <br /> Owner's Name ' ! Phone <br /> Address aiM City - <br /> Contractor's Name License /r137X.4Business Phone_ <br /> Contractor's Address O + Emergency Phone <br /> Is,Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes5e No W <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ d <br /> WELL CHLORINATION ❑ WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRS '. <br /> REPLACEMENT❑ r i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 9-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information Jj <br /> ❑ GEOPHYSICAL Surface Seal Installed <br /> PUMP INSTALLATION: Contractor ov C j <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work DoneRtbi <br /> es <br /> DESTRUCTION'OF WELL: Well Diameter Approximate Depth a <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 forwhich 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 /> In" ; <br /> I ill call for a Grout In" c ' n or o grow ng and a final inspection. <br />-t Signed X Title: _.—_.T.r+t,SS - Date: <br /> I` {Draw Plo . Ian on Reverse Side) - <br /> I FOR DEPARTMENT USE ONLY "F <br /> PHASEI 66 <br /> Application Accepted By �S Date 7 Od <br /> Additional Comments: <br /> Phase`III Grout Inspection Ph -if .Final Inspection <br /> Inspection By Date - Inspection By ` ' Date 7` '•� <br /> Iw - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> _ BASE - � EXPLANATION - AMOUNT DUE CHECKED ` <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION I' <br /> PLUS I� # <br /> PENALTY ` <br /> OTHER �I <br /> OTHER - <br /> �3 770 ✓ ' <br /> Received by DateI Receipt No. - -Permit No. ' Issiiiance Date Mailed livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E:HAZELTON AVE.,P.O.Boa 2CKTON,CA 95201 <br /> 6� <br />