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" ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> -4A 1aJ4 (For Non-Transferable, Revocable,Suspendable) <br /> 1 <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaq,u))n Co nt Ordin ncL.��jjNo.• 862 and the rules aqd regulations of the San Joaquin Local Health District. <br /> Exact Site Address 'f✓ t+6 •/�'� � o 00, City/Town q <br /> /&wner's Name 1 J Phone <br /> Address City- <br /> Contractor's <br /> ity Contractor's NamevsJCaG License#Business Phone <br /> Contractor's Address ;� 6 <br /> ��"" • Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes�[ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN REGONDITION❑ DESTRUCTION❑ I <br /> WELL 'CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR r <br /> REPLACEMENT❑ t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines - , Pit Privyf'w1 <br /> Sewage Disposal Field = <br /> 9 P Cesspool/Seepage Pit Other_ _ <br /> Property Line Private Domestic Well Public Domestic Well <br /> "INTENDED USE TYPE OF WELL t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑,DOMESTIC/P.RIVATE ❑ DRILLED r Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN- a Gauge of Casing <br /> IRRIGATION ' ❑,GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY, Type of Grout <br /> ❑ DISPOSAL ❑ OTHER_ Other Information I <br /> ` t i <br /> ❑ GEOPHYSICAL tSurface Seal Install y: r ®3 <br /> PUMP,INSTALLATION: Contractor_ <br /> t CID, <br /> Type of'Pump H.P. <br /> PUMP REPLACEMENT ❑ State Work Done <br /> PUMP REPAIR:- «I �R-State-Work Done c.► <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---t <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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." II <br /> I will fall for a Grout Inspection r It gr tin 0 <br /> nd at' al inspection. <br /> Signed X t3 <br /> Date: 2,e <br /> (Draw Plot n on Reverse Side) <br /> F R DE ARTMENT SE ONLY <br /> PHASE I <br /> Application Accepted By Date,-- / O <br /> Additional Comments: <br /> Phase It Grout inspection <br /> ��j�Ialspection <br /> Inspection By Date Inspection By;oUDate <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 1 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> - a <br /> AMOUNT <br /> FEE <br /> sf <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER. <br /> OTHER { <br /> 7 <br /> Received by .'�a', - :Date Receipt NoPermit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601'E.WA2ELTON AVE.,P.O.Box 2009 STOCi(TON,CA 95201 <br />