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Appli AIIA Processed When pitted Properly Completed. sesure Ioalgn rne..NN,r..a...... <br /> FOR:OFFICE USE: v n <br /> APPLICATION <br /> MAYn 1 �l '980 ,�.�., I <br /> l A ( or�)Von`-T`ransierable, Revocable, Suspendable) PUMP&WELL <br /> SAN �oAQUjjg6MENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) HEALTH p��TR1CT WATER QOALITY. <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 <br /> made in compliance w �aquin County qrdinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town yy1 <br /> Exact Site Address <br /> 1 r <br /> Phone <br /> Owner's Namex <br /> Address 2 City <br /> License# G Business Phone <br /> Contractor's Name �� t' <br /> 7f Yj Emergency Phone t <br /> Contractor's Address [� No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 1 <br /> REPLACEMENT❑ <br /> Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Sewage Disposal Field Cesspool/Seepage Pit Other P <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL _ Y <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 19 DOMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing <br /> i ❑ DRIVEN Gauge of Casing <br /> ik 13DOMESTIC/PUBLIC ? <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 11 DISPOSAL <br /> ❑ OTHER Other Information ) <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br />° PUMP INSTALLATION: Contractor <br /> i Type of Pump f <br /> PUMP REPLACEMENT: State Work Done <br /> �+ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> k I hereby certify that 1 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 /> 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 shall employ persons subject to workman's compensation laws of California.' <br /> i I will ca ivr �ullnsp�e,,tlonrior to grout <br /> and a sinal inspe on. .S <br /> _--» K Date: <br /> Title: <br /> F Signed X <br /> (Draw Plot Plan on Reverse Side)' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> b Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection as Ill Final Inspection rr�e <br /> Inspection By Date P <br /> Inspection By Date `- <br /> ❑ PER UNIT ❑ PER SITE El EACH C1 January 1 &Received By January 31 © July 1 &Received EMBy uly 31 <br /> Fee IS Due:-❑ ANNUALLY IT <br /> kBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE HATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY <br /> OTHER a <br /> OTHER <br /> .355 <br /> ate 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 2099 5TOCKTON;CA 952111 <br /> Received by <br />