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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheAppllcauon. �t <br /> FOR OFFICE USE: APPLICATION <br /> X. .df (For Non-Transferable, Revocable,Suspendabie) PUMP&WELL <br /> "{ ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY1,. <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work hher6in described.This application is <br /> erei <br /> made in compliance with San Joaquin ounty]Ordinance No. 1862n�d the les and regulations of the San Joaquin Local District. <br /> l Q uE"y iX 0 ' ; y/Town <br /> Cit _ <br /> Exact Site Address r <br /> Phone.. <br /> Owner's Named ..> <br /> Address City <br /> Contractor's Name � - <br /> "'License# •►` Business Phone <br /> Contractor's Address + Emergency Phone. <br /> No .. <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes <br /> TYPE OF WORK (CHECKS NEW WELL❑" DEEPEN ❑ 'RECONDITION 11 - "'DESTRUCTION-0 f <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ . OTHER 11 PUMP INSTALLATION PUMP REPAIR❑ `l <br /> REPLACEMENT❑ + v 1 <br /> DISTANCE TO NEAREST: Septic Tank T Sewer Lines-I- <br /> Sewage <br /> Privy <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 /> 9DOMEST.IC/PRIVATE ❑ DRILLED Dia. a Wel! Casing <br /> 11DOMESTIC/PUBLIC 11 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 /> 11 GEOPHYSICAL ,. Surface Seal In aped By: <br /> Contractor ,S+o ' <br /> PUMP INSTALLATION: I _ <br /> - Type of Pump ' H:P.+ <br /> PUMP REPLACEMENT: �. State Work Done <br /> PUMP REPAIR: State Work Done ' <br /> ' Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <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 /> 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> i permit is issued, i shall employ persons subject to workman's compensation laws of California.., , <br /> I it call for a Grout Inspectionn-pno ou g an final inspection. <br /> Date: � <br /> Signed X <br /> (Draw Plot Ian on Reverse Side) <br /> -FOR DEPARTMENT USE ONLY <br /> '"PHASE i Y Date <br /> Application Accepted <br /> Additional Comments: <br /> Phase II.Grout Inspection Phase 111 Final Inspection <br /> - Inspection By �Vni Date <br /> Inspection By Date a <br /> 1 1 &Received B January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY PER UNIT` El SITE EACH' .❑ January y REMIT <br /> r $ CHECKED <br /> BASE EXPLANATION - BILLING REMITTANCE <br /> DATE DATE' REMITTED AMOUNT DUE AMOUNT <br /> FEE ` <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> Received by - <br /> Date Receipt No Permit No. .. . _ Issua ce Qat Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOC1(TON,CA 952111;-' - <br />