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Applications Will Be Processed When Submitted Propeny -ornp,e«w. o� ��•� � a _ <br /> FOR OFFICE USE: - APPLICATION <br /> (For Non-Transierable, Revocable,Suspendable) pUMP&WELL , <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> WATER QUALITY <br /> (COMPLETEaKTRIPLICATE) <br /> Applica�;•on is hereby made to the San Joaquin Local Health Di permit construct and/or install the work herein described.This application Is <br /> made in compliance with Sane uin my Orditl nce No 1862 and th rul san�,o, <br /> sof the San Joaquin Local Health District. <br /> ty/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name <br /> Address <br /> City �� <br /> Contractor's Name 5 • License# d 3 Business e ' <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes�_ No t� <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ W <br /> WELL CHLORINATION 11 WELL ABANDONMENT El OTHER E] PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ I` IO r <br /> Se <br /> 'DISTANCE TO NEAREST: Septic Tank / �` Sewer Lines Pit Privy <br /> e <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 /> El DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE �•1 <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing 16(� <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 6 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ter, <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well 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 <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi call for a Gr ut 1 ection rior to grout' g and a final inspection <br /> Date: _11191 7 <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPART ENT USE ONLY <br /> PHASE I [j4/7 <br /> 01tidl. Dake <br /> Application Accepted By <br /> Additional Comments: 0< <br /> Phase 11 Grout Ins c on hase Ili Final Inspection f oZ <br /> Inspection By Q R. pate /a fi Inection By a e l <br /> 1b rlI5s�-7q IST— {t+ - a1 <br /> Fee IS Due: C1 ANNUALLY PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 ❑ July 1 &Received <br /> y July 31 <br /> IT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE `7 3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ■ OTHER <br /> Es -7 �11b S 7 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.§�2009 STOCATONw CAS 1 <br />