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-y Applica ill Be PrZeskid h ed Properly Completed. Be Sure To Sign The Application T <br /> - <br /> FOR OFFICE USE: PLICATION <br /> 11 - <br /> 4UG 13("Mn-T rable, Revocable, Suspendable) <br /> SAN J ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) "E4LrHlD/N LOCAL WATER QUALITY <br /> Application is hereby made to the San Joaquin Loca�Hl3dittrflistrict for a permit to construct and/or install the work herein described.This application is' <br /> made in compliance with San Jo a LACounty4prdinance o. 1862 d rules and regulations of the San Joaquin Lo al Health District. <br /> Exact Site Address .•��Qp Z ' <br /> City/Town �r <br /> Owner's Name --7 <br /> Phone <br /> Address 7 ity i <br /> Contractor's Name 1�'T'}� ��/� License# Business Ph ne <br /> Contractor's Address Emergency Phone IVIS U <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION RV-- PUMP REPAIR❑ <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> wProperty Line _ Private Domestic Well Public Domestic Well <br /> INTENDED USE - TYPE OF WELL � - <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 71 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seai .} <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout k <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL z Surfa Sea J _Ins II d By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .7 v H.P. 3 <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 { <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 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 iss shall employ ns subject to workman'AInspec tion laws of California." <br /> I w' c a o f Inspect! prio to grouting a d a finall �Signed X _ Titl Date: <br /> (Draw Plot Planoide) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I - r7 c� 1 <br /> Application Accepted By Date G'/ <br /> Additional Comments: <br /> Phase 11 Grout Inspection ha incl Inspection _ <br /> Inspection By Date Inspection By w Date �/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By Jan ary 31 ❑ July 1 &Rec - d By July 31 <br /> REMIT <br /> BILLING REMITTANCE - <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS / v <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER f <br /> OTHER <br /> - Y - <br /> - <br /> Receivetl by Da[e Receipt No. Permit No. :Issuanc Date Mailed <br /> y- . AVE.,P.O.Box 2009 Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 EHAZELTON AYESTOCKTON.CA 95201 1 <br />