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ApplicationsWill Be Processed',yhen 5ubmftted-Prope I r o `- n <br /> r w FOR OFFICE USE: pplication. „ <br /> APPLICA <br /> {For Non-Transferable, Rev Su ]e able} <br /> E 1979 PUMP&WELL <br /> ;t <br /> ENVIRONMENTAL HEALTH T w <br /> (COMPLETE IN TRIPLICATE) WATER QUALITNSAN JOAQUIN LOCAL <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to cons ' <br /> �+�tA�idP�IJ :��tTi�'�}�prTc heroin described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1882 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Towne <br /> Owner's Name J. <br /> Address Phone <br /> city— <br /> Contractor's Name <br /> Contractor's Address License# Business Phone p <br /> ,� <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK {CHECK}: NEW WELL 13DEEPEN 11RECONDITION El 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 <br /> � P6 , .. <br /> � erty Line Private Domestic Well Public Domestic Well - <br /> INTENDED USE �` TYPE OF_WELL. <br /> ❑ INDUSTRIAL <br /> !' f1 1 10`13 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 7 <br /> Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY -Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL a Surface Seal Installed By: <br /> PUMP INSTALLATION: y <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done A4_0I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> 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 <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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X - Title: <br /> -Date: <br /> (Draw Plot Plan on Reverse Side) <br /> OR DE ARTMENT USE ONLY 71 <br /> PHASEI <br /> Application Accepted By Date–�r <br /> Additional Comments: <br /> _ Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By�� Date inspection By L Date <br /> Fee Is-Due: 1.1 ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January`& y Re ed By ua y 31 � El �;Jg `ed 31 <br /> `BASE EXPLANATION BILLING REMITTANCE $� RE T <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT I <br /> Alf <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER I <br /> OTHER ^� - <br /> - a33 �l - f <br /> a Received 6y Date Receipt No. Permit No. Issuan a Date Mailed Delivered <br /> ---.AP.PLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> - "--- 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201'-- '� <br />