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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION }` Z�,�- (For Non-Transferable,Revocable, Suspendable) _ PUMP&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> :t <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thew ork.he. <br /> described.This application,is <br /> made in compliance with aquin Co my Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> -r Phone- <br /> Owner's Name <br /> Address City <br /> Contractor's Name License#25 D �c� Business Phtine: 6` <br /> C: 6v� ency Phon ` '�" <br /> Contractor's Address Emergd'' <br /> Is Certificate of Workman's Compensation Insnce on File With SJLHD? Yes NO r 6` <br /> TYPE OF WORK (CHECK): NEW WELL Ll' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE r TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL pia. of Well Excavation r j - <br /> )0---DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 5 <br /> ❑ DOMESTIC/PUBLIC El DRIVEN Gauge of Casing <br /> i <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout ',V, <br /> LA <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 0 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 /> Homeowner 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 fallowing:"I certify that in the performance of the work forwhich this <br /> compensation laws of California." <br /> permit is issued, I shall employ persons subject to workman's <br /> I for a Grout Irlspecti prior t routin nd a final inspection. q t <br /> Date: <br /> Signed X <br /> Title:" <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE IC� �y <br /> Application Accepted By <br /> ,U Date b <br /> Additional Comments: <br /> r P e 11 rout Inspecilon as�lll Fi?al Inspection <br /> inspection <br /> By Date �~ I� kl Inspection By ✓ W, Date <br /> Fee Is Due: C3ANNUALLY ❑ PER UNIT ❑ PER SITE 11EACH ❑ anuary 1 &Received By'January 31 © July 1 &Received By July 31 w_ <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE ' <br /> A ° <br /> LESS <br /> PRORATION <br /> 'PLUS o. .. <br /> PENALTY <br /> i <br /> OTHER ' <br /> OTHER <br /> Received by Date Issuance DateMailed Delivered <br /> eceipt No. Permit o. _ . - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCK70N,CA 9520 <br />