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ApplicationsWill BeProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) / <br /> � <br /> ENVIRONMENTAL HEALTH PERMITPiZ/':r?&WELL" <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby mad,,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 with San Joaqul County Ord'nan No. 1862 and the rules and r ulatio sof h S`an Joaquin Local Heafith District. <br /> Exact Site Address a5 — 1 T /�1-- <br /> Owner's Name PhoneJ�— <br /> Address City pd <br /> Contractor's Name ` _ License# �fD�/� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Ice on File With SJLHD? Yes X No D <br /> nsura <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field A062 r Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> El H <br /> INDUSTRIAL_ 11 CABLE TOOL Dia. of Well Excavation <br /> .DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing X <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Cts <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout A2 <br /> ❑ DISPOSAL ❑ OTHER Other Information C� <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H p <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth ll l <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will 11 for a Grout spec ' /',�prLior to grouting and a final inspection. <br /> Signed X tG7 Title: Date: .� <br /> (Dra lot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> P s I Gr ut Inspection Phase 111 Fina�,lnspection <br /> y <br /> Inspection By Date _ Inspection By y Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE • .� C O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date I Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />