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1 �, <br /> Lz�ir <br /> ,A attons Wilk&P,.,-. ss—ed-1�ubmitted Properly Completed.Be Suri J Sign The Application. <br /> FOROFFICE USE: 9 MAR � 319s82 APPLICATION <br /> (For Non.Transferable,Revocabi;,Suspendable) PUMP&WELL <br /> SAID '� -UIN L5t]MONMENTAL HEALTH PERMIT O <br /> (COMPLETE IN TRIPLICATE) <br /> y� TH DISTRICT WATER QUAUTY <br /> Application is hereby madeto 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. 8 •and the r les nd regulations of the San JoAguin Local Health District_._ <br /> Exact Site Address City/Town <br /> i Owners Name ` Phone s <br /> r, City <br /> Address <br /> Contractor's Name ITn= License# /II!? Business Phone ? <br /> Emergency Phone �0�`"� <br /> Contractor's Address �; £A '11 � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No <br /> TYPE OF WORK (CHECK)- NEW WELL 13 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 /> • Sewage Disposal Field Cesspool/Seepage Pit' Other <br /> Property Line Private Domestic'WeILt' Public Domestic Well <br /> INTENDED USE TYPE OF WELL ,. <br /> i ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dla.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 Sufface Seal Installed By: _ <br /> PUMP INSTALLATION: Contractor 71 c Cil <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done f f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: r 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 Lbcal Health District. Q <br /> Home owner or licensed agent's signature certifies the following:"I certiN 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." <br /> Contractor's hiring or sub-contracting signature certifies the foltorving:"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 /> t i call or a;en�s7pe.qon;prior o groutin�and sinal Inspection_ �1 <br /> 5lgned Title: nate: ✓� - <br /> .(Draw Plot Plan on Reverse Slde) t <br /> FOR DEPARTMENT USE ONLY <br /> PRASE l <br /> Application Accepted By ' %6va - Date , <br /> Additional Comments: <br /> rse 111 Final ins ase!1 rout Inspection Inspection <br /> P � P <br /> Inspection By r Date Inspection By cs gate ka A " r— <br /> Fee Is Due: ❑ ANNUALLY r, ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 . ❑ July 1&Receivee'By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE' CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ®. <br /> x <br /> LESS r' <br /> PRORATION <br /> Y Ptos <br /> PENALTY- <br /> OTHER { <br /> OTHER <br /> hirceived by - I Date Receipt No. Permit No. -Issuance Date �Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HAZELTON AVE..P.O.BOX 2009 aTQ"TON,CA 95201 <br />