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Applicatlons Will Be Processed When Submitted ProperlyCompleted. lieSure Iosign ineAppucaion. <br /> FOR-OFTICE USE: APPLICATION <br /> w (For Non-Transferable, Revocable, Suspendable) s <br /> - � PUMP&WELL <br /> ENVIRONMENTAL,HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ��+ WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District for a permit to construct an /or instali th4wor rein described.This application is <br /> made in compliance with San Joaquin County Ordinance No- 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ' EDF / 1 Z Eity/Town �-� &7V 7:5 C'� <br /> Owner's Name OEp ' Phone <br /> Address L�� I�rC'ilLf}Nd iM 1 t! City 3Ty[a� A/, ['_4- ya 09 F <br /> Contractor's Name License#3�7a� Business Phone 7 — 3�� i <br /> Contractor's Address t�� Bc�xf. "� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ � IO ( ,} <br /> W I <br /> TYPE OF WORK (CHECK): NEWELL� 13DEEPEN RECONDITION❑ DESTRUCT <br /> WELL <br /> W, V� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR El <br /> REPLACEMENTEI <br /> DISTANCE TO NEAREST: Septic Tank La�� Sewer Lines A-1 E-_ Pit Privy <br /> Sewage Disposal Field 1�dy�`�- Cesspool/Seepage Pit Other y <br /> Propelrty Line_Private Domestic Well IV Public Domestic Well f <br /> INTENDED USE, TYPE OF-WEELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE 1� <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> � IRRIGATION <br /> 11 GRAVEL PACK Depth of Grout Seal <br /> /❑ CATHODIC PROTECTION ! ❑ ROTARY Type of Grout <br /> s GC�/T �L��L-T <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor I <br /> � Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> � Approximate Depth Z� <br /> Describe Material and Procedure <br /> ,I v prepared this application and that the work we <br /> 1 hereby certify that I ha e p p PP kill bdone 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,llagent'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 for which this <br /> permit is issued. I shall employ persons subject to workman's compensation laws of California." <br /> l�. <br /> I will all for a Gr ut Inspection prior to grouting and a final inspection. <br /> s�-� <br /> Date: fp� <br /> Signed XTitle: <br /> .�. M <br /> (Draw Plot Plan on Reverse-Side)` v-.. <br /> I; FOR DEPARTMENT USE ONLY <br /> PHASE I �, <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> ha III Grout Inspectioas }II n nspection <br /> Inspection Byte` tate 3 i Inspection fay <br /> Fee Is Due-. 13ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &'Received By January 31 E] July 1 &fleceived By July 31.' i <br /> REMIT <br /> BASEEXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> p DATE DATE REMITTED AMOUNT <br /> FEE h <br /> F LESS <br /> PRORATION I� <br /> PLUS �� <br /> PENALTY <br /> OTHER I� <br /> OTHER <br /> . I <br /> {` Date s `Receipt No Permit No. Iss ance D tr+ Mailed Delivered <br /> •-• Received by _ <br /> . APPLICANT--RETURN ALL COPES TO: �ENYIRONMENTAL HEALTH PERMIT/SERVICES - - 160}E.HAZEL-TON AVE.,P-O.J3ci 2009- ' S70CKTON,GA 45201 _ <br />