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n Moil l.auv ns WillII ue r ULC ,%I*u ry Lieu .7u0 l it ileu vivpeny %.;ojoitieteu. ue ,ure to Alyn I lie Appicaiwit. <br /> I FOR OFFICE USE- APPLICATION <br /> �. ,mor Non-Transferable,Revocable,Suspendable) PUMP gi WELL <br /> f, <br /> ENVIRON MENTAL HEALTH PERMIT <br /> ,COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work hereih described.This application is <br /> made in compliance with S n Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Head District. <br /> rte. <br /> 1 :xact Site Address City/Town <br /> t <br /> owner's Name Phone <br /> �ddress �7� City <br /> .,ontractor's Name 'S License If S��jb 9b Business Phone <br /> I <br /> ontractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_Lef:�:_...__ No <br /> WYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> ELL CHLORINATION ❑�7 WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1 <br /> REPLACEMENT© �y <br /> (STANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line ` "Private Domestic Well Public Domestic Weil` ' <br /> INTENDED USE TYPE OF WELL <br /> j INDUSTRIAL------- ❑ CABIrE TOOL—. _.._ _ ...__---flia.of Well Excavation - <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC © DRIVEN Gauge of Casing <br /> IRRIGATION © GRAVEL PACK Depth of Grout Seal i <br /> CATHODIC PROTECTION ❑ ROTARY _ Type of Grout .� <br /> —tl DISPOSAL ❑ OTHER Other Information U <br /> GEOPHYSICAL Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor ' G <br /> 'Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑State Work Done <br /> FIMPREPAIR: ❑ Stale Work Done. <br /> STRUCTION OF WELL: tl� Well Diameter yr Approximate Depth <br /> Des 'be Mat rial and Proced re <br /> } <br /> t <br /> hereby certify that I have prep ed this application an at the work will be done in accprdance with S 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, 4 shall not employ any pgrson 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 /> x permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I/wiilll call for a Grout Inspection prior to grouting and a final inspection. <br /> ��1 / �y <br /> t iigned X Title: bate: <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPARTMENT USE40NLY <br /> r x PHASE I_ _ <br /> i i <br /> Application Accepted By— �._... .__. .. -.___. _ Date �, <br /> Additional Comments: <br /> Phase.11.Groul Inspection ha I11 F' I Inspection <br /> L Inspection By I' Date Inspection By Date_ 11 <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By'January'31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> 1 BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> I AMOUNT <br /> FEE Vol <br /> { <br /> LESS ! <br /> - PRORATION <br /> PLUS I � <br /> PENALTY 14 <br /> OTHER <br /> t <br /> 1 <br /> OTHER <br /> i - <br /> i <br /> Received by ,s "bate - ""Recaipt'No"'-- "'Permit No:"-'" ' . . Issuance Date Mailed Delivered <br /> f <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES IMI c MA7PI Tnu evt: 0 n 0—Iona ernr-rTnu ra aaam <br />