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Applications Will Be Processed When Submitted Froplany GomPlelev. WWw- �•� ^rr <br /> ,FOR OFFiCF;USE: . APPLICATION <br /> Cts 15/*4 (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> E w.� ENVIRONMENTAL HEALTH PERMIT <br /> s" • <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaciluin Local Health District. _ <br /> Exact Site Address aCity/Town <br /> Owner's Name ea IF r%I Phonen r <br /> f S' City <br /> Address , �,, ,r <br /> m License# /4 1 Business Phone <br /> r Contractor's Name <br /> Contractor's Address Emergency Phone <br /> I's Certificate of Workman's Compensation Insurance on File With SJ HD? Yes NO <br /> TYPE OF WORK (CHECK): NEW WELL El ❑DEEPEN ❑ RECONDITION DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION 0► PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> y, DISTANCE TO NEAREST,. Septic.Tank Sewer Lines Pit P.rayy■'"*'�"r"` <br /> Sewage Disposal Field w Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well L <br /> INTENDED USE _ _ TYPE OF WELL `" <br /> j ❑ INDUSTRIAL ❑ CABLE TOOL Dia.--of Well Excavation r <br /> DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing 1 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 7 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed-By: <br /> r PUMP INSTALLATION: Contractor <br /> Type of Pump H-P' �— <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP­ "fir+ 19 <br /> State Work Done <br /> DESTRUCTION OF WELL: Well Diameter RAp roximat epth <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 SanJoaquin Local Health Distric <br /> ' <br /> Homeowner 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 /> T Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 I Wjo call for a Grout}ns ecli pri r t grou 'ng and a final inspection. <br /> F Signed itie: Date: <br /> {Draw Plo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /T= <br /> Application Accepted B Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 11 Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH, ❑ January 1 &Received By January 31 r ❑ July 1 &ReceiveRdEBylJuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE -$ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> Date Receipt No. Permit No. - `- Issuance Date Mailed De'vered <br /> Received by - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICE5 1601 E.HAZELTON AVE.,P.O-Box 20 KTON,CA 95201' <br />