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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: t APPLICATION ' <br /> _V e411hp16I' .,\ (For Non-Transierable, Revocable, Suspendable) , <br /> _ PUMP&WELf., <br /> ENVIRONMENTAL HEALTH PERMIT T t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Coup Ordinance No 1862 and t rules and regulations of the San Joaqu Lo I ealth District; <br /> Exact Site Address -i" .+ City/Town <br /> Owner's Name 1714.1 11 Phone A <br /> Address 6 �' City <br /> Contractor's Nam a License #/f-W 74:=Business Phone "IF44 l —?rG a <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ - DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ ' <br /> c REPLACEMENT❑ <br /> O , <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines _ Pit Privy <br /> Sewage Disposal Field bCesspooI/Seepage Pit Other <br /> Property Line__ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> J4 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Inst By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .mit d-d:.-- y P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done lk <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. k <br /> Homeowner 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."h <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this„ ..I�.r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection pri to o nd a final inspection. <br /> Signed X le: Rnw Date: __ ' 07 <br /> (Dr w Plot an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase it Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> k <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By Jwy 31 <br /> k <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED t <br /> DATE DATE REMITTED AMOUNT- <br /> FEE <br /> MOUNTFEE <br /> a7 <br /> LESS <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> _ -7 G7g f <br /> Received by Date Receipt No. Permit No. Issua a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2yW'RPCKTON,CA 95201 <br />