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Applications Will Bei Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE_u E;:' APPLICATION <br /> — �" (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <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 County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address SCS.G City/Town Dom. d <br /> Owner's Name 1) , ,Phone 0.6 <br /> Address <br /> City 0 <br /> Contractor's Name Picense#a7� Business Phone q I <br /> i <br /> Contractor's Address !6� �3 _0_.4&_ r Emergency'Phony <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes r No <br /> t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT% { <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> r I <br /> Sewage Disposal Field Cesspool/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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> R ❑ GEOPHYSICAL Surface S al installed By: <br /> PUMP INSTALLATION: Contractorltt„ <br /> Type of Pump. _ H.P. <br /> PUMP REPLACEMENT: ,V 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'l 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 /> Homeowner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this permit ` <br /> is issued, I shall not employ any iperson 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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: (� <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE I <br /> DEPA TMENT U E ONLY - - <br /> Application Accepted By - �-- ----- - <br /> Additional Comments: Date <br /> i <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date F <br /> Fee Is Dug: ❑ ANNUALLY ❑ PER UNIT W PER SITE ❑-EACH ❑ January 1'&Received ByJarivary 31 ❑ JuVy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATI BILLING REMITTANCE $ " <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �� F <br /> LESS <br /> PRORATION v <br /> PLUS +u <br /> PENALTY f 2, e vYJ6 t [ C�, <br /> r <br /> OTHER /,-JD Dh< 01h(7. . <br /> 4,yr GV'-f`Ci Y f <br /> OTHER i O i� iG Cz J✓rra// Art) rr <br /> A <br /> G�,,,r�t v W i� i+l a a- <br /> i <br /> Ct1 11 --7S7 ,x i <br /> -7'NReceived by Date, ti Receipt No.. y .Permit No. ."_.I seance Date Mailed_r Delivered <br /> l4ppL1CANT—RETURN ALL COPIES TO: E H PERMIT/SERVICES 16171 E.HAZELTON�AYE. P.O.-BaK 2 4,W-sT0CKT0N,CA 952614 YW r <br />