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Applications,Will-Be Processed When Submitted rop <br /> 17 <br /> FOR OFFICE USE; _. APPLICATION <br /> ii (For Non-Transferable, Revocable, Suspendable) PUMP&WELL + <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ,I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San JoaquiinnfCounty Ordinance No. 1862les and d regulations of City/TownheSan <br /> Exact Site Address Joaquin Local Health District. <br /> ` /''fir LJ <br /> P r Phone_ <br /> a <br /> Owner's Name City <br /> Address W16 <br /> icense# Business Phone O <br /> Contractor's Name <br /> Emergency Phone --� <br /> Contractor's AddressNo —� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ MENTDEEPE❑❑ <br /> OTHER 11 ITI PUMP <br /> INSTALLATION ❑� PUMP REPAIR© <br /> WELL CHLORINATION ❑ WELL ABANDON <br /> j REPLACEMENT❑ i Pit Privy <br />[F Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line - Private Domestic-Well <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> El INDUSTRIAL �� 11 CABLE TOOL Dia. of Well Excavation <br /> � X DOMESTIC/PRIVATE <br /> DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC �! ❑ DRIVEN Gauge of Casing <br /> I, ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION i= <br /> 11 CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> ❑ OTHER Other Information <br /> [I DISPOSAL '' Surface Seal Installed By: <br /> I ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ii ❑ State Work Done <br /> PUMP REPAIR: II <br /> ❑ State Work Done <br /> Well Diameter +�E��+� Z^/�'�' Approximate Depth <br /> { DESTRUCTION OF WELL: <br /> # � Describe Material and Procedure � <br /> A- 1461 <br /> lU <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 licen1.sed agent's signature.certifies the following:"I certify that t the performanceofthe anon l work r sof Cali permit <br /> is issued, I shall not employ any person n 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 /> t permit is issued, I shall employ persons subject to workman's compensation laws of California." w <br /> I will call for a Grout Inspection prior to grouting and a final inspection. !✓Z .. IS _ �0 <br /> AVI Date: <br /> ` Title: . <br /> Signed X <br /> i � (Draw-Plot on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 ,i Date <br /> Application Accepted By <br /> r Additional Comments: ase III FI al Inspection <br /> Phase 11 Grout Inspection Date r �� <br /> Inspection By <br /> Date Inspection By <br /> i <br /> Fee IS Due:-❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH C1 January 1 &Received By January 31 ❑ July 1 &Received <br /> EMITJuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> j BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I FEE / 3 <br /> LESS <br /> 1. PRORATION <br /> PLUS 1 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by q Date Receipt No. Permit No <br /> , Issuance Date Mailed Delivered —�+-�/ <br /> ., 1601'E..HAZELTON AVE.,P.O.Box 2009 sTOCr(TON,CA 9526 <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 10 <br />