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-FOR OFFICEui uuiu,u� �N „r uni��ccci.. v� t I v f <br /> use: APPLICATION <br /> ,I <br /> . (For Non-Transferable, Revocable, Sus <br /> pendabE <br /> ENVIRONMENTAL HEALTH PERMIT J PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY V <br /> Application is hereby made to the San Joaquin Local Health District <br /> for permit to construct and/or install the work erein es <br /> made in compliance with San Joaquin Count OrdinI►s a <br /> Y ane o. 4862 and_trules_and regulations of the San Joaquin Local Hea th District, is <br /> Exact Site Address �-� <br /> Owner's Name <br /> City/Town �l <br /> •;��� — - --� -'-�� <br /> Address k C Phone._. <br />' Contractor's Name City <br /> � <br /> Contractor's Address I License Business Phone 2-3 rJ <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ["' <br /> TYPE OF WORK (CHECK): NEW WELL❑ No <br /> DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 'PUMP INSTALLATION ❑ PUMP REPAIR Fr' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Pro ert Line Other <br /> P .Y Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL i <br /> © INDUSTRIAL CABLE TOOL <br /> Dia:Of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> '❑ DOMESTIC/PUBLtC ❑ Dia. of Well Casing <br /> a DRIVEN <br /> ❑ IRRIGATION Gauge of Casing <br /> ❑ GRAVEL PACK Depth-of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> El +,. Type of Grout <br /> ❑ OTHER <br /> 13 GEOPHOther Information <br /> YSICAL = ` <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor V- F, <br /> 1 Type of Pump .r:� H.P. <br /> PUMP REPLACEMENT: I. ❑ State Work Done <br /> PUMP REPAIR: <br /> DESTRUCTION OF WELL: Well Diameter <br /> AP Y <br /> '. Describe Material and Procedure <br /> is <br /> re ared this P P s application and that t11e ork will be done in a ordanc with San Joaquin County <br /> I hereby certify that I have <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> 4, Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich 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 f0llawing:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will c l for a Gr ut Inspection Prior to grouting and a final lnspectl <br /> J ! <br /> Date: <br /> Signed X Title: <br /> «< <br /> (Draw Plot Plan on Rev rse Side) <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE I i <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase III Grout Inspection <br /> Inspection By Date <br /> Ph se III Final Inspection f <br /> .Inspection 8y <br /> Date. <br /> Fee IS Due: 1:1 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH i <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE E REMIT 11 <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE ! AMOUNT <br /> LESS <br /> PRORATION : <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER !¢ <br /> jam, <br /> Re eived by Date 1 -3 <br /> Receipt No. Permit No I seance ate <br /> Mailed' Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br /> 1601 E. TON AVE.,P.O.Bo:2009 <br /> _. HAZELSTOCNTON,CA 95201 _ <br />