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ow <br /> Applications Will jBe'Processed When Su APPLICATION # <br /> FOR OFFICE USE: <br /> f„F (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health f7istrictfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cou.ty O inance'No. 1862 an t e rules and regulations <br /> of the San Joaquin o I Heal h District. <br /> Cit <br /> Exact Site Address <br /> Phone <br /> Owner's N e City <br /> Address License# Business Phone <br /> Contractor's Name Emergency Phone r� <br /> f Contractor's AddressNo V <br /> 1 Is Certificate of Workman's Compensation Insurance on File With SJLHD?' Yes N <br /> TYPE OF WORK (CHECK NEW WELL ABANDONMENT ❑❑ OTHEE CDEEPENl iTIO PUMP❑MP INSTALLATION ❑DESTRUCTION❑ PUMP REPAIFI� 1 <br /> WELL CHLORINATION WELL <br /> 4 REPLACEMENT❑ Sewer Lines Pit Privy <br /> f DISTANCE TO NEAREST: Septic Tank,- Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line 7 Private Domestic Well i <br /> r INTENDED USE •,TYPE OF WELL <br /> ❑,CABLE TOOL Dia,of Well Excavation <br /> ❑ INDUSTRIAL Dia of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRILLED mow. <br /> { 13 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC - Depth'of Grout Seal <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> 13ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION Other Information <br /> 13 DISPOSAL <br /> 11 OTHER <br /> Surface Seal Installed By: <br /> E] GEOPHYSICAL <br /> 3 <br /> IF <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump t <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> :I C1 State Work Done <br /> 4 <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter ,T <br /> Describe Material and Procedurebe I <br /> I hereby certify that I have preparehis applicatioons oflati the San Joaquin Wworkwill <br /> ilHeaRone in cordate with San Joaquin County <br /> Health District <br /> ordinances, state laws, and rulesd 9 <br /> Home owner or licensed agent's signature <br /> such manner followias to become subject to workmany that in the 's compensation nce of the work f laws of Califon alt <br /> is issued, I shall not employ any person <br /> e <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the per <br /> of the work iorwhich this <br /> ject to workman's compensation laws of California.” <br /> permit is issued, I shall employ persons sub , <br /> j I will call to a Grout Inspection nor to grouting and a final Inspection. <br /> Title: Dale: <br /> Signed X <br /> (Draw Plot Plan onReverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> f Application Accepted By <br /> Additional Comments: Phas III Final Inspection <br /> ll Grout Inspection Date <br /> inspection By Date <br /> Inspection By <br /> € Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORAT40N <br /> PLUS <br /> PENALTY <br /> v OTHER ff <br /> OTHER l <br /> Receipt No: Permit No. Issuance Date Mailed Delivered <br /> eceived by Date <br /> 16'1 E.HA2ELTON AVE.,P.O.8vx 2009 . STOGxTON,CA 95201 _ <br /> .. APPLICANT--RETURN ALL COPIES TO: ENYIRONMENTAL'HEALTH PERMITISERYICES - „f <br />