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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL 1fw/ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , <br /> rY A l't <br /> Application is hereby madetothe San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is y <br /> made in compliance with Sa i Joaq/uin� fCoun rdinanpe o. 1862 d the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town 17 �p "-i . <br /> Owner's Name �, /+ Phone <br /> Address �� r L City .y��-G�/0 <br /> Contractor's Name Tec r, License# Business'Phonet6-�`KZ - <br /> Contractor's Address z- 2J Emergency Phone' ' <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes X No <br /> TYPE OF WORK (CHECK): --NEW WELL❑r' DEEPEN ❑ RECONDITION❑-_"-DESTRUCTION❑ p� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER S[ PUMP INSTALLATION PUMP REPAI_ <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank «t Sewer Lines - Pit Privy <br /> { <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line I Private Domestic Well Public Domestic Well <br /> INTENDED USE 'TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> �❑d DOMESTIC/PUBLIC © DRIVEN Gauge of Casing I <br /> lar IRRIGATION t 13 GRAVEL PACK ri Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL r ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 4 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: ❑•State Work Done <br /> PUMP REPAIR: State Work Done— o_ee""� <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 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." <br /> I will c fora Gro Inspection prior to grouting and a final inspection. l / <br /> Signed X Title: Date: �( � <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE.I T� fiL/ A -01-13 Date <br /> Application Accepted By_ ' <br /> Additional Comments: <br /> as I rout Inspection Phase III Final Inspection <br /> Inspection By I Date Inspection By Date S <br /> Fee IS Due: Cl ANNUALLY -'❑ PER UNIT PER SITE ❑ EACH 1' " ❑-'January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE - 'EXPLANATION .BILLING -t-_ -. REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE ! DATE REMITTED AMOUNT <br /> FEE 7-� -�� <br /> LESS <br /> PRORATION <br /> PLUS T.. <br /> PENALTY <br /> OTHER <br /> OTHER i <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST0CW1_ <br />