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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: , APPLICATION <br /> 1f (For Non-Transferable, Revocable, Suspendable) <br /> — ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 4 Application is herebymadetothjj--Sanda n ocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplicationi <br /> made in compliance with San Jd�qulnt Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address /��_L�/Wt/ �- City/Town <br /> Owner's Name lq7U Phone <br /> Address _ City .1?A!/%�5'�O�t> <br /> Contractor's Name -eL) S icense#3 6 OJS / Business Phone XV-7— 0,3 94Z <br /> r Contractor's Address QS /CPr� ,ea 20 Emergency Phone gS4'7— U-;;, 94C <br /> E Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLO DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> t REPLACEMENT❑ . / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines �� Pit Privy <br /> Sewage'Disposal Field ��fi y Cesspool/Seepage Pit _ A-) Other <br /> t Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> A DOMESTIC/PRIVATE ElDRILLED Dia. of Well Casing A S_ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> S ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal d <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> i ❑ GEOPHYSICAL _ Surface Seal Installed By: . <br /> PUMP INSTALLATION: Contractort37�% <br /> Type of PumpH.P. �- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: a❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth.- - <br /> Describe Material and Procedure <br /> 1 <br /> 1 <br /> t, 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. <br /> f <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." <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 siffi <br /> rsons subject to workman's compensation laws of California." <br /> will call for a G oufor lo grouting and a final inspection. <br /> Signed 1 Title: Xe�rz�� '� Date: / U <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By � Date <br /> Additional-Cb`mmen <br /> 1 Phase II rout inspection Phase III Final Inspection <br /> nspection By Date Inspection By_ �L 1�a Deli <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER IT EACH ❑ January 1 &ReceivedBy.January 31 ❑ July 1 d Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> ANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE /2 l 13LESS <br /> PRORATION f fie(/y` s vU�r <br /> .e <br /> PLUS6 /n es ruh O <br /> I_ t !L PENALTY �{.Gi ,P IF �C= Z <br /> OTHER q 1 4fp J Po vet <br /> -OTHER <br /> Je <br /> ws 4f <br /> s Rec wed by Dae 1 Receipt No. Permit No. Issuance Date Mailed Delivered <br />