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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> z ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY _ . , _ . ,.. •t n <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or installthework herein described.This application Is <br /> ade in compliance with n un ounty, r finance No.1862 stud th,e s and reg tat one of the San JoagulwLocal Health Disyct. <br /> • City/Town <br /> Exact Site Address Phone <br /> T <br /> Owner's Name _ Phone <br /> Address 47 f '" - - City <br /> Contractors Name 1` r cense 11 gOV, Business Phone_ <br /> ! ;fr'Emergency Phone <br /> Contractor's Address <br /> \ Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No <br /> TYPE OF WORK(CHECK): NEW WELL E3 DEEPEN ❑ PRECONDITION DESTRUCTION❑ r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER_❑ PUMP INSTALLATION PUMPREPAIR❑ 1 <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 WEL -_�– f 14 <br /> ❑ INDUSTRIAL -CABLE TOOL• --- Ula. of yyell Excavation <br /> I ❑ OOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> 0ay DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 1 <br /> 9FRIGATION -E] GRAVEL'PACK -- Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 11 DISPOSAL Other information <br /> ElGEOPHYSIt AL Surface Seal Installed B <br /> PUMPANSTALLATION: - Coy <br /> n raptor f/ <br /> I <br /> Type ol.bumpf_ -- HP ` <br /> PUMP REPLACEMENT:. 11 state Work-Done <br /> PUMP REPAIR: ❑ State Work Done f I <br /> 1 - Approximate Depth <br /> DESTRUCTION OF WELL: � Well Diameter .. _ <br /> .� Describe Material and Procedure <br /> I hereby certify that I.have prepared thisapplication and that he work will be done m accordance kitKSan Joaquin County <br /> ordinances,state laws,-and rules and regulations of the San Joaquin Local Health District. . <br /> Hofiteownerorfieensed agent's signature Certifies the following;"I certif,yy thatintheperformenceof the okforwhichihispermit <br /> is issued I shall not employ any person in such manner as to becomeCbjeb,"rrf}'o workman's.pomperisdtion laws of California." <br /> CoAtraetor's hiring or sub-contraeting■Ignature certifies the following:"I cerlifythat In the perfordtance ollhwork for which this <br /> per,nit is issued, I shall employ persons subject to workman's compensation laws of California" . <br /> .v. for a Or nspectio grouti a final ins tion. <br /> " signed.X -- Title: D$le: <br /> (Draw Plot Plan on ReR rse Side) <br /> I - O FOR DEPARTMENT USE ONLY <br /> ApA4 <br /> Application Accepted By= v - . Oate, <br /> Additional Comments; <br /> Phase 11 Grout Inspection _.Pt)ase III��Final��pection <br /> Inspection By Date — Inspecticn BY@y _ G.nate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT -PER SITE. L3 EACH f ❑ January1 a Recerveo By January 31 (� July 1 6 Received July 31 <br /> REMMIT <br /> SASE "EXPLANATION BILLING REMITTANCE f AMOUNT WE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> PLUG .- . ... <br /> PENALTY t <br /> OTHER <br /> OTHER <br /> Received by <br /> N '-Dare Receipt Perm11. b. - e•n are Mailed' . p,H.. - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEaMIT/feRYIC1 1601 E.HA LTON AVE.,P.O.eea 20110 IsTOCKTON,CA 96201 r <br />