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Applications Will Be Processed When Submitted Properly Completed. Be S Sign The Application. <br /> APPLICATION ,'". . <br /> FOR OFFICE USE: �^. <br /> -�•- ;� (For Non-Transferable, Revocab�;�S pAdat) <br /> \ PUMP&WELL <br /> ENVIRONMENTAL ERM% <br /> (COMPLETE IN TRIPLICATE) <br /> WA U TY O�� <br /> Application is hereby made to the San Joaquin Local Health District for a p o cor}sltvU�t d/or instvp, ork herein described.This application is <br /> made in compliance with San Joaquin Count Ordinance No. 18 2 and th s an regulati tla� oaq,pin Local Health District, <br /> Exact Site Address , Q ' �� \wn SCS <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name Vicense#/l 2. 73 Business P h o n e <br /> Contractor's Address 0 Emergency Phone 7 Eo- 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 h <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field' Cesspool/Seepage Pit Other y <br /> Property Line '" Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation m <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED^ '"' " —Dia:of W60 Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> i ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout d <br /> El DISPOSAL E] OTHER Other Information # <br />` ❑ GEOPHYSICAL t - - /Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor e' f <br /> Type of Pump n: H.P. s <br /> PUMP REPLACEMENT: ate Work-Done - —V ��` d <br /> PUMP REPAIR: ❑ State Work Done ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth -; <br /> i 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 /> 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 t <br /> t ..-is issued,'-[.shall not.employ-any-person.an_such_manner-as-to_become.subject to workman's compensation-laws of California." r, <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;w!�all ;aGrou�tpecfionprio7to grouting and a final insp>;ciion. <br /> Signed X Title: / Date: <br /> (Draw P t Ian on Revers Side) <br /> FOR DEPARTMENT.USE ONLY r. <br /> PHASE I �0,3©- <br /> Application Accepted By Date <br /> Additional Comments: <br /> 1`y Phase III Final Inspection <br /> Phase II Grout Inspection � <br /> Inspection By �Date Inspection Bye to <br /> Fee Is Due: ❑.ANNUALLY ❑ PER UNIT' y ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION Z. _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> l OTHER <br /> ! Received by Date Receipt No. *Permit.No I suanc Pate Mailed Delivered <br /> (_ 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />