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�. Applications Will Be Processed When Submitted Properly Completed. aSureTo <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) ( PUMP&WELL <br /> Y. ENVIRONMENTAL HEALTH PERMIT / <br /> �'� - wATER QUALITY <br /> (COMPLETE IN TRIPLICATE) n r N j� <br /> Application is hereby made toth SanJoaqulnLocalH althDistrictforapermittoconstruct and/or install theworkherein described.This application is <br /> made in complian' itfi San Joaquin County Ordinance No. 186 and the rules and regulations of the San Joaquin L�cai,ealth District. <br /> —� City/Town _T <br /> Exact Site Address <br /> Phone <br /> Owner's Name ! . <br /> E Address City _Z <br /> ` <br /> Contractor's Nam .,License �1 _ Business Phone <br /> � I <br /> i <br /> Contractor's Addres Emergency Phone s <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �h <br /> WELL CHLORINATION 1:1 WELL ABANDONMENT ❑ ; 'OTHER E] PUMP INSTALLATION 8— PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 /> f ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ©/DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑� DO £STIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> L�`IRRIGATION 13 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER j� Other Information <br /> 11 GEOPHYSICAL �urface Seal 1ta ed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done <br /> t PUMP REPAIR: 11 State Work Done <br /> I t Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> tt ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> i 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 Zertifies the following:"I certify that in the performance of the work for which this <br /> r <br /> permi s issued;I shall employ pErso s subject to workman's compen ation laws of California. <br /> I wl call for a Grout Ins Clio pr' r to. uting and a final inspe. on. `/C� <br /> Signed X y <br /> ! Title: <br /> Date: v <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPART ENT USE ONLY <br /> PHASE I G Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout inspection � e Ill Fi I Inspections 7 � <br /> Inspection By <br /> Date Inspection By Date 7 <br /> Fee I5 DUO' ❑ ANNUALLY El PER UNIT i PER SITE ❑ EACH El ,anuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> I ASE EXPLANATI N BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT . <br /> FEE ! <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY * <br /> OTHER <br /> OTHER <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by101 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlfiERYICES 1601 E.HAZ£LTON AVE.,YEP.O.Box 2009 STOCi(TON,CA <br />