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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. _ <br /> FOR=OFFICE USE: <br /> 4 APPLICATION <br /> { (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 6 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is S <br /> made in compliance with San Joaquin County OriVnance N . 1862 and the rules and regulations of the San Jo uinL al Health District. <br /> Exact Site Address f f ��"1 41A City/Town <br /> Owner's NameQ Q r^ r Phone <br /> Address e 2 N{' City <br /> Contractor's Name - +1. Ir License# to i�7 Business Phone �r <br /> Contractor's Address Ln 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❑ 0 <br /> REPLACEMENT❑ LA, <br /> kk DISTANCE TO NEAREST: Septic Tank'- Sewer Lines Pit Privy r <br /> f 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 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 0 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 00 <br /> dc1 ; r <br /> DESTRUCTION OF WELL: Well Diameter - <br /> 8 Approximate Depth <br /> D s ribe aterial and Pr ted re 64- 1 Cost <br /> H w r 3 r <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. <br /> Home owner 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 /> t Contractor's hiring or sub-contracting signature certifies the following:"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 /> I will call for r u Ins tion prior to grouting and a final inspection. <br /> Signed X Title: .1/I Dater <br /> (Draw Plot Plan on Reverse Side) <br /> FORT T USE ONLY <br /> PHASE l <br /> Application Accepted By <br /> Date �8 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> t Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE, ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE- EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I <br /> FEE 41 <br /> LESS # <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 2/ma91 <br /> f Received by Date Receipt No. Permit No. Issuance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: } ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STQ TON, 5201 <br /> e e , 77 - �C <br />