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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) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ;I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San ou <br /> Joa uin County dinance No. 162 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ; a 1-� /`i'L I <br /> City/Town <br /> i( <br /> Owner's Name 7 f rCr � Phone I <br /> Address City 'N <br /> Contractor's Name 1 � icense# Y� _ Business Phone <br /> i Contractor's Address Emergency Phone II <br />[- Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ` _ No <br />+ TYPE OF WORKi.(CHECK): NEW WELL KI DEEPEN ❑ RECONDITION-❑ DESTRUCTION❑ Ii <br /> r WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONO PUMP REPAIR❑ v <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank � ) Sewer Lines Pit Privy Ii <br /> Sewage Disposal Field Cesspool/Seepage Pit Other i <br /> Property Line`` Private Domestic Well y/r Public Domestic Well <br /> INTENDED USE TYPE OF WELL i <br /> 3 ❑�I'N DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED . Dia. of Well Casing II <br /> ❑ DOMESTIC/PUBLIC <br /> t ❑ ❑ IVEN <br /> Gauge of Casing <br /> IRRIGATION AVEL PACK Depth of Grout S <br /> CATHODIC PROTECTION ROTARY e <br /> l <br /> Type of Gro ' <br /> ❑ DISPOSAL ❑ OTHER Other Inform ' n { II <br /> ❑ GEOPHYSICAL Surface Seal Installed B <br /> i Y; <br /> ,PUMP INSTALLATION: Contractor + <br /> 4 <br /> jType of Pump H.P. �+- <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ F <br /> State Work Done <br /> DESTRUCTION OF WELL: f l Well Diameter <br /> 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 I` <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health <br /> Homeowner <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 forwhich this ! <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection pr4or to grouting and a final inspection. f <br /> Signed X I Title: Date: �Z —.2-7 <br /> f (Draw Plot Plan on Reverse Side) <br /> I 4 <br /> ' FORDEPART NT Up ONLY , <br /> PHASE I � � <br /> k <br /> Application Accepted By-- , _- Datefa'3� <br /> Additional Comments: <br /> Phas Grout Inspection ri Ph4de IR Final Inspection i. <br /> Inspection By_/?k Date _ Inspection By Date ✓ ` <br /> Fee IS Due: ❑ ANN A Y <br /> U LL ❑ PER UNIT ❑ PER SITE ❑ EACH Cl-Januar 1 &Received B Januar 31 <br /> y y y 1July 1 &Received By'Julfy 31 . <br /> BILLING REMITTANCE <br /> BASE 'EXPLANATION REMIT <br /> $ <br /> AM N <br /> OU T DUE CHECKED <br /> I� DATE PATE REMITTED AMOUNT� <br /> FEE <br /> LESS <br /> PRORATION + <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER ° <br /> OTHER - -- -- -- <br /> Received by Date Receipt No. - - Permit No. „. I suanc Date Mailed Delivered {} <br /> :n a. <br /> APPLICANT—RETURN ALL COPIES TO: ENYIR®NMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P:O.Box 2009 STOCXTON,CA 95201 <br />