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ApplicationsWill Be Processed When Submitted Properly Cam <br /> FOR OFPF1rCE USE: d. Be re To Sign The Application, <br /> APPLICATIONrr <br /> (For Non-Transferable, Revocable, Suspendable) 'LA <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein drib d.T <br /> made in compliance with San oa uin Count Ordinance N 1862 nd the rules and regulations of the San J a uin Local Health District. <br /> O_ _ Q This application is <br /> Exact Site Address � p t!-7` <br /> L �� <br /> Owner's Name City/TownOlt <br /> ��. 1 <br /> Address E Phone Z <br /> Contractor's Name L 1110 City " <br /> Contractor's Address icense# (� Busine s Phone Z+ <br /> nc <br /> Is Certificate of Workman's Compensation insurance on File With SJLHDmergYesy phone <br /> s TYPE OF WORK (CHECK): NEW WELIL� DEEPEN ❑ RECONDITION❑ No <br /> F WELL CHLORINATION 11WE_LL ABANDONMENT ❑ DESTRUCTION❑ I <br /> F REPLACEMENT❑ .y OTHER ❑ PU_ MP INSTALLATION ❑ PUMP REPAIR❑ ! <br /> DISTANCE TO NEAREST: Septic Tank T A�� /� } <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Feld <br /> Cesspool/Seepage Pit <br /> Property Line- - Private Domestic Well <br /> INTENDED USE public Domestic Well Other <br /> ❑ INDUSTRIALTYPE OF WELL fir <br /> ❑ /„ <br />�_ DOMESTIC/PRIVATE CABLE TOOL Dia. of Well Excavation IQ 7 Ye <br /> ❑ DRILLED Dia, of Well Casing L a <br /> DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATIONGauge of Casing <br /> El GRAVEL PACK Z a <br /> ❑ CATHODIC PROTECTION Depth of Grout Seal <br /> ❑ DISPOSAL ROTARY Type of Grout <br /> ❑ GEOPHYSICAL ❑ OTHER Other Information <br /> PUMP INSTALLATION; Contractor Surface Seal Installed By: <br /> Type of Pump <br /> PUMP REPLACEMENT: i <br /> ❑ State Work Done H.P. <br /> PUMP REPAIR: 0 State Work Done <br /> DESTRUCTION OF WELL; <br /> �Welf Diameter— <br /> Describe Material and Procedure --`""Approximate Depth i <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 H_eaith District. <br /> Home owner or licensed agent's signature certifies the followin # <br /> is issued, I shall not employ any person in such manner as to becomefsubject to workman'sencompensation ce of the work f aws Of California." <br /> It f <br /> Contractor's hiring or sub-contracting signature certifies the following;"I certify that in the performance of the work forwhich this <br /> Permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> wi tl for a Grout Inspection prior to'.roufin <br /> g g and a final inspection. <br /> Signed X <br /> Title: <br /> (Draw Plot Plan an Reverse Side) ¢`¢"Date:Z 6 <br /> PHASE ! FOR.DEPARTMENT USE-ONLY r <br /> �� <br /> Application 14 <br /> Accepted By /�iG j <br /> Additional Comments:- _ _ DateZ- <br /> Pha I ul Inspection <br /> Inspection By Date !— — It F' /I- nspection-�. �. <br /> Inspection By Date <br /> Fee IS Dile; ❑ A NUALLY ❑ PER UNITk <br /> ❑ PER SITE ❑ EACH ❑ January 1 &R ived B Januar 31 <br /> I Y Y ❑ July 1 &Received By July 37 <br /> BASE EXPLANATION BILLING REMITTANCE - $ REMIT <br /> fi DATE DATE REMITTED AMOUNT CHECKED <br /> FEE AMOUNT <br /> LESS <br /> PRORATION <br /> -PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ' 1 k <br /> Fl-­vu by Date <br /> Receipt No Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ...ENVIRONMENTAL HEALTH PERMIT/SERVICES Iss ante Date Mailed Delivered <br /> 1601 E.HAZELTON,,AVE:,P.O.Box 2009 STOcrrnw <br />