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- . • Applications Will Be Processed When Submitted Properly Comple -retjSe Application. <br /> FOR OFFICE USE: APPLICATION <br /> _• (For Non-Transierable, jbl)!�Siftendable) <br /> ENVIRONMENTATHj PUMP&WELLWATER(COMPLETE IN TRIPLICATE)Application is hereby made to the San Joaquin Local Health Districtforapermittoconstrue ardle <br /> �d 40 herein described.This application is <br /> made in compliance with San Joa in ounty Ordinance No. 18 nd the rules an�JSa�Jaqu�ino Health District. Q <br /> Exact Site Address 7'�7� -� t',City/Town <br /> ` Owner's Name Phone _ - <br /> Address City <br /> Contractor's Name /� License#/�, - 7 3_ Business Phone <br /> Contractor's Address_. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> .j DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit 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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ <br /> ❑ ROTARY Type of Grout r !CATHODIC PROTECTION <br /> ❑ DISPOSAL' ❑ OTHER Other Information <br /> ' ❑ GEOPHYSICAL Surface Seal Installed By: = <br /> PUMP INSTALLATION: Contractor <br /> f > Type of Pump T ` -H i <br /> PUMP-REPLACEMENT: _ = ❑ State Work Done <br /> PUMP REPAIR: i ti State Work Done rp- <br /> DESTRUCTION OF WELL: Well Diameter >` Approximate Depth <br /> Describe Material and Procedure <br /> }-I hereby certify that I•:have prepared this application and•that the work will be done in accordance with San Joaquin County <br /> 'Cordinances, 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-eM loy-any=person-iri 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 /> j permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I <br /> I will c or at-In`spe 'on prior to grou ng and a final inspection. �' 7 <br /> j Signed X Title: Date: r / <br /> 91�41]iraw Plot Plan on RevergdSide) <br /> ! FORD PARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date �9 <br /> Additional Comments: <br /> t Phase 11 Grout InspectionP III Fin I Inspection <br /> Inspection By Date Inspection 13& Date,/!a <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r i REMIT <br /> 1 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE r S <br /> - _ 4 <br /> LESS <br /> p PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i <br /> -71­y6nz <br /> t Date Receipt No. -Permitt No. Issuance Dat Mailed Delivered <br /> Received 6y , <br /> E APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />