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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. �r <br /> FOR OAUSE: APPLICATION <br /> t (For Non-Transferable, Revocable, Suspendable) '`* <br /> +��-� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> F Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules andre I tions of the San Joaquin Local Healt District <br /> Exact Site Address �' f 7i City/Town <br /> Owner's Name IVL Phone <br /> Address � � C��_ City ����: 1 <br /> Contractor's Name /�F�.(,C.0 '� .�}�; License#�G��'!-� Business Phone I - ' <br /> Contractor's Address Emergency Phone - r- <br />{' Is Certificate of Workman's Compensation IM a on File With SJLHD? Yes�Xzz <br /> No <br /> 4 TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <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 i <br /> ❑ INDUSTRIALi <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED6 <br /> Dia. of Well Casing <br /> � . <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION IKGRAVEL PACK Depth of Grout Seal V <br /> ❑ CATHODIC PROTECTION U40TARY Type of Grout CrJtQJ V € <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ff <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ 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 /> 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 any1person 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 wil call for a Grout Ins p ion prior grouting and final ins con. <br /> Signed X i-(�L •T11te Date: <br /> (Draw Plot Plan on Reverse Sid <br /> a <br /> FOR-DEPARTMENT USE ONLY { <br /> PHASEI , <br /> Application Accepted By Date <br /> Additional Comments: - <br /> Phase II Grout Inspection Phase 111 Final Inspection i <br /> Inspection By Date Az!S, Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE `❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUN70UE CHECKED <br /> AMOUNT I <br /> FEE � <br /> �� ,� ► , <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER' 1 <br /> Received by I DaIA Receipt No. Permit No, I suance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: EN IR- ----AL HEALTH PERMIT/SERVICES5 <br /> 1601 E.HAZELTON AVE.,A.O.Box 2009 STOCK <br /> TOA 95201 (' <br />