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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. f , <br /> FOR OFFICE USE: APPLICATION I <br /> (For Non-Transferable;Revocable,Suspendable) - / <br /> PUMP&WELL /y <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSan Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is <br /> made in compliance with Joaquin County Ordinance No. 1!852 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 1/v. 111.10111-105 /7 ' City/Town rii�l�tj <br /> Owner's Name M /7 SOH/l/1 A t)4 IF""" Phone <br /> Address ov ks M1, ,P_I/)N/ /_h ffp City S799C& G <br /> Contractor's Name G`'/A/?10� wezlie !�I o C:/', Fdf!,nse #3 7f�Ie© Business Phone <br /> - "R <br /> Contractor's Address "X -4y12,?7L VVI f Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes — No i <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION�DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy , <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑�4NDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> I' <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r <br /> Ix IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H,P, <br /> PUMP REPLACEMENT: O'State Work Done . <br /> PUMP REPAIR: ❑'State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> h <br /> Describe Material and Procedure <br /> s <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 the work forwhich 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 �t <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." 1 <br /> rfor IS:�rjpinspecti <br /> prior to grouting and a final inspection. <br /> Signed X _t� _ Title: Date: <br /> i} (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE [ <br /> Application Accepted By Dateo 0.114 <br /> Additional Comments: <br /> Phase II Grout Inspection Ptlasq III Final Inspection <br /> Inspection ByM Date Inspection By \�_- Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jufy 1 &Received By July 31 - <br /> REMIT <br /> BELLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> r <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date ka Receipt No., Permit No. 1,ssuance Clate I Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STO_ � _ <br />