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Applications-Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> F FOR OFFICE=USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> -- PUMP&WELL <br /> ENVIRONMENTAL 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 herein described.This application is <br /> made in compliance with San Joa u' oun y rdinance No. 18 a rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Towns <br /> Owner's Name Phone D i <br /> Address City r <br /> Contractor's Name C, 1icense36 .2 Eiv Business Phone 7--d Scy �I <br /> Contractor's Address ft\ Emergency Phone �7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No +� <br /> TYPE OF WORK (CHECK): NEW WELL Mr DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION © WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION �PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank :y— Sewer Lines Pit Privy ' �- <br /> Sewage Disposal Field /Ldk e- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> IA-DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing lI/ . <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 3--ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHY5ICAL �� Surface Seal Installed B� �iJ� <br /> PUMP INSTALLATION: Contractor / - <br /> Type of Pump r.rt,ox-C H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> Home owner 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 peirson 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 /> o <br /> ued, I shall em persons subject to workman's compensation laws of California." <br /> r a Gr u p coon prior to grouting and a final inspection. <br /> Title: �b�� I�i /l Date: <br /> {Draw Plot Plan on Reverse Side} t <br /> FOR DEPARTMENT USE ONLY <br /> � Qxppepted By `-'� Date �w`'' <br /> Additional Comments: I <br /> hase II Grout Inspection 9�y Phase III Final Inspection�p �� <br /> Inspection B I Date )CP �O Inspection By Date Oi+` . <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT I <br /> FEE `—"— <br /> LESS i <br /> PRORATION <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 68$ 3 <br /> Receivedby-wiiiiiiiii� Date Receipt No. Permit No Issuance Date Mailed Delivered { <br /> E. <br /> APPLICANT RETUfity�L COOPIETTO ENYIRONMENTAI:HEALTH PERMIT/SERVICES ,,�c�.r...1601.E:HAZELTON AYE.,P.O.Box 2009 STOCKT011 CA 95207_ - <br />