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Applications Will Be Processed When Submitted Properly Completed. Be 1T Sign The Appli n. <br /> FOR OFFICE USE: APPLICATIQN �U 2 <br /> (For Nqn-Transferable, Revocable;Suspendable) PUMP& <br /> ENVIRONMENTAL HEALTH PERMITr�1ac``L�� �tA. <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S [-���L-CH IDIS-vRiCT ~ <br /> Application is hereby madeto theSan Joaquin Local Health District fora permit to construct and/or install the work.he described.This application is <br /> made in compliance with San Joaquin.Cou Or 'n n e 1862 and the rules an re �ations of the San Joa uin oval Health District. <br /> Exact Site Address / �. <br /> ity/Town " <br /> Owner's Name <br /> Phone �`Q <br /> Address City <br /> Contractor's Name <br /> License# f Business-Phone. Q. <br /> Contractor's Address OSF '� 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 11 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ vvv���t <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy _I:- w <br /> Sewage Disposal f=ield Cesspool/Seepage Pit Other M <br /> Property Line Private Domestic Well Public Domestic Well LJ <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 /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ' ❑ State Work.Done <br /> DESTRUCTION OF WELL: Well Diameter / n / <br /> J— TsApproximate Depth <br /> Describe Material and Proceduret� <br /> �doe <br /> G hereby certify that I have prepared this application and t t work will in accordant 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 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ill all f r a Grout In pecti n prior t routing and a final inspection. <br /> Signed X " (A <br /> Title: Date: <br /> (Draw Plot Pian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE t <br /> Application Accepted By Q 6r�-81 <br /> Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection aincl speCtion <br /> Inspection By Date spection BY Hate <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31'BILLING REMITTANCE.REMITTANCE REMIT - <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED i! <br /> DATE DATE REMITTED AMOUNT I <br /> FEE <br /> LESS r U <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I! <br /> OTHER <br /> k <br /> Received by Date Receipt No.- - _ Permit No. - _ ua ce Date Mailed .Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 15131 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />