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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE;: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> I ENVIRONMENTAL HEALTH PERMIT I PUMP&WELL <br /> F JCOMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance-wi o uin-Countya e No-48fi2 anrJ the ruies-and-regulations of-the San Joa in Loc alth District. <br /> Exact Site Address C+s r <br /> - - �# - - - - _ City/Tow <br /> Owner's NameYZZ <br /> _ - 1 <br /> Address — r� Phone <br /> Contractor's Name City <br /> Contractor's Address _ License#�Z(��Q 'BL1 i Pe;s Phone — <br /> Is Certificate of Workman' Emergency Phone <br /> s Compensation Insurance on File With SJLHD? <br /> 3 YesTYPE OF WORK (CHECK): <br /> NEW 'pEEPEN ❑. RECONDITION❑ I?_E_STRUCTION <br /> VIP <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ <br /> REPLACEMENT❑ PUMP REPAIR <br /> DISTANCE TO.NEAREST: Septic Tank Sewer Lines <br /> i Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> � OtherPro <br /> Property Line � Private Domestic Well _o <br /> Public Domestic Well j <br /> INTENDED USE � TYPE OF WELL _ <br /> ❑ INDUSTRIAL CABLE TOOLu <br /> ❑ DOMESTIC/PRIVATE Dia, of Well Excavation I <br /> ❑ DRILLED Dia. of Well Casing 9 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11 IRRIGATION Gauge of Casing /- . <br /> ❑ CATHODIC PROTECTION GRAVEL PACK Depth of Grout Seal <br /> 1:1DISPOSAL ROTARY , <br /> Type of Grout. . <br /> ❑ <br /> ❑ GEOPHYSICAL OTHER Other Information <br /> PUMP INSTALLATION: .Surface Seal Installed :I <br /> Contractor E , <br /> Type of Pump H.P. <br /> CP MP REPLACEMEN ❑.State.Work-Do.ne <br /> PUMP REPAIR: ❑j State Work Done.- <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 k <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. r j <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which thispermitI <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 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 wI call for a Grout InspeFtion Dior to grouting and a final inspection.Y <br /> Signed X� <br /> Title: l Date: ! <br /> (Draw Plat Plan on Reverse Side) <br /> FOR:DEPARTMENT USE ONLY a <br /> PHASE ] <br /> Application Accepted By <br /> t <br /> Additional Comments: Date t <br /> Phase ll Grout Irispection <br /> Inspection By�/�, ti i Date La _ Phase 111 final Inspection <br /> Inspection By _ Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 37 ❑ July 1 &Received By July 31' <br /> RASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> I DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION - <br /> PLUS c <br /> PENALTY <br /> OTHER <br /> ! <br /> OTHER - <br /> Received by Dale,- t � <br /> Receipt No. - Permit No. Issua ce pat <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed - Delivered <br /> s <br /> 1601 E.HgZELTON AVE.,P.O.Bv><2009 - 570CIrTMt ea <br />