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Applications Will Be Processed When Submitted ProperlyCompleted. tae Sure Iosign InePtpplrcalwr,. \ <br /> oil- FOR OFFICE USE: t. APPLICATION I\, <br /> - (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made totheSan Joaquin Local Health Districtforapermit toconstruct and/or installtheworkhereindescribed.Thisapplicationis I <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> �o I 5c,. City/Town <br /> n.` . . .n <br /> Exact Site Address �.��w� <br /> •� Phone <br /> Owner's Name J--/ � ,r <br /> Address City ��`� <br /> r - S=? ASO <br /> Contractor's Name License#ti �� _ Business Phoneme _ <br /> Contractor's Address <br /> © - Emergency Phone 5vr_� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ w DESTRUCTION❑/ © I <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION L- PUMP REPAIR <br /> REPLACEMENT❑ \ <br /> DISTANCE TO NEAREST: Septic Tank" Sewer Lines Pit Privy t <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 11 <br /> ❑., INpUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 7 <br /> U-150MESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing 4 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ( Surface Seal Installed By: <br /> p <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done i� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure S <br /> t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County A j <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 /> ill lo Grout I pection prior to grouting and a final inspection. <br /> Signe V Title: Date: . <br /> k (Draw Plot Plan on Reverse Side) <br /> a FOR DEPARTMENT USE ONLY <br /> 1 <br /> PHASE I Date <br /> I Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Ph Final Inspection <br /> Inspection By Date Inspection By Date a�— <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &ReceiveRdEByl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE' CHECKED <br /> 'I DATE DATE FIEMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> r, PWS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -Date - I Receipt No. Permit No. Issuance Date Mailed ed <br /> " APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 2009 - OCKTON,CA 95201 <br /> .16U1 E.HAZELTON AVE.,P.O.Box <br />