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ApplJja nVJ- M41B"raes1edtV 6MPPLICATION <br /> itted Properly Completed, BeSureToSign TheApplication. <br /> ' <br /> FOR OFFICE-USEi � %� <br /> -- ' SEP � Qr�Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> EN,�!11fLNMENTAL HEALTH PERMIT <br /> sA. WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) II AAll TN DISTRICT lication is <br /> Application is hereby made to the Sg",in Local Health Districtfora permit to construct and/or install the work herein described.This app <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town���•S S��} TC� iI <br /> Owner's Name w Prl T � ) Phone <br /> Address City l / <br /> lness Phone <br /> Contractor's Name License# � <br /> Contractor's Address )Emergency Phoe q� y <br /> Is Certificate of Workman's Compensation Insura a on File With SJLHD? Yes No k <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ I <br /> REPLACEMENT # <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> n Sewage Disposal Field Cesspool/Seepage Pit Other i <br /> Property Line Private Domestic Well Public Domestic Well # <br /> INTENDED USE TYPE OF WELL t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing # <br /> G <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 <br /> Type of Pump H P <br /> PUMP REPLACEMENT: State Work Done t <br /> PUMP REPAIR: Q State Work Done s <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r <br /> Describe Material and Procedure I <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 /> Nome 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 torwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> a Grout lnspec pri grout' and final inspectio } <br /> I <br /> Signed XTitle: ` Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEcv <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection nal spection <br /> Inspection By Date Inspection By Date <br /> y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Julyeceived B 31 .I <br /> i REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE - EXPLANATION DATE DATE REMITTED <br /> AMOUNT I <br /> cFEE s I <br /> LESS �. <br /> PRORATION <br /> PLUS <br /> PENALTY ' -- <br /> OTHER <br /> a <br /> k OTHER <br /> Received by Date Receipt No. Permit No. - Isl;uanc6 Date Maned Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE6, �_ 1601 E.HAZ£LTON AVE.,P.O.Box 2009STOCKTON,CA 95201 <br />