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Applications Will Be Processed When Submitted Propeny Lompletea.aeaury rV y, •� err -� <br /> [FOR-GIFFICE use: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> z ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) 4 uctand/orinstallthework herein=described.Thisapplicativnis <br /> Appl ication is hereby made to the San Joaquin Local Health District for a permit to constr <br /> made in compliance withISan oaqui�Count Ordin a IN 1 62 a d the rule a regulations of the San alth District. <br /> Exact Site Address CCe✓ � City/Town <br /> _ <br /> Owner's Name rte. Phone <br /> City <br /> Address Oil <br /> Contractor's Name +cense Business Phe <br /> Emergency Phone t <br /> Contractor's Address0 J <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No t <br /> TYPE OF WORK (CHECK): NEW WELLY DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ME�rlq` L,'y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION❑ PUMP%; 1* <br /> REPLACEMENT❑ �9 �,�� <br /> TO NEAREST: Septic Tank rQ eC/ Sewer Lines esspoa age pit i :7- <br /> DISTANCE Other <br /> Sewage Disposal . — I <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑,-1, CABLE TOOL Dia. of Well Excavation— <br /> Dia. <br /> ❑l DPMESTIC/PRIVATE IrsDRILLED Dia. of Well Casing <br /> l DOMESTIC/PUBLIC ❑ DRIVEN - Gauge of Casing <br /> ❑ IRRIGATION 1:1 GRAVEL PACK: Depth of Grout Seal r <br /> 112-.ROTARY -CATHODIC PROTECTION Type of Grout <br /> ❑ DISPOSAL* ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: S <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump H.P. e l <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done [� <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County g <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 for which this permit zt i <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 c I to spection prior to grouting and a final inspection. / ; <br /> /Y^ a <br /> Signe X <br /> Title: ` Date: <br /> (Draw Plot Plan on Rever a Side) <br /> FOR DEPARTMENT USE ONLY ' <br /> i <br /> PHASE I II`�'�'�- ( Date <br /> Application Accepted By ` <br /> Additional Comments: <br /> Ph it Grout Inspection'? III Fin b Inspection <br /> a <br /> Inspection By Date /`�� Inspection By Date <br /> I Fee Is Due: ❑ AN ALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receitdd By January 31 ❑ July 1 &.Receiv d By REMITuly 31 <br /> BItHNG REMITTANCE $ AMOUNTDUECHECKED <br /> BASE EXPLANATION <br /> DATE DATE REMITTED' , i 2 AMOUNT <br /> FEE 3 {4x <br /> LESS �.. <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4Issuance ate Mailed Delivered <br /> ' Received by Date Receipt No, Permit No. <br /> 1661 E.HAZELTON AVE.,P.O.Box 2009009N,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERV10ES � <br />