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Applications Will BeProcessed When Submitted Properly Completed. Be Sure To Sig Application. <br /> FOR.oFfICE USE: <br /> APPLICATION <br /> ' <br /> Ii <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL fJ <br /> (COMPLETE IN TRIPLICATE)'O'- �'i Lc t WATER QUALITY ! <br /> T Ccs_ ._., ��' 7 .1 <br /> made <br /> compliance <br /> hereby made to the San Joaquin Local Health District fora Permit to construct and/or install the work herein described.This application is <br /> made incompliance wit San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address <br /> fCity/Town I <br /> Owner's Name the If <br /> t � =i <br /> Address Phone <br /> Contractor's Name �N'f!� JIC Bus I <br /> License#fkT- Business Phone h <br /> Contractor's Address! I, rvEmergency Phone 4v� <br /> Is Certificate of Workman's Compensation Insuran on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank- S <br /> ,I. � ewer Lines fit Privy 1 <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit ether <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE + <br /> TYPE OF WELL ! <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC ❑ Dia. of Well Casing <br /> DRIVEN Gauge of Casing <br /> gi-IffRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL ❑ OTHER Type of Grout y <br /> ❑ GEOPHYSICAL Other Information <br /> i Surface Seal Installed By: - w <br /> PUMP INSTALLATION: � Contractor <br /> Type of Pum H P <br /> PUMP REPLACEMENT: ❑ State Work Done _- <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 [ have prepared this application and that the work willbe 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 lig:"I certify that in the performance of the work for wcensed'agent's signature certifies the following. { <br /> hich 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." i <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ! will call for a Grout InsipVorior to grouting and a final inspects a <br /> Signed X Titl <br /> I� (Draw Plot Plan on Reverse Side) Date: Z_ <br /> FOR DEPARTMENT USE ONLY a <br /> PHASE I I <br /> r ! <br /> Application Accepted By � �� <br /> Additional Comments: �M Date <br /> ri <br /> Phase I! Grout Inspection <br /> Inspection ByI� Pha III Final Inspection <br /> Date <br /> Inspection BS Date <br /> Fee Is Due: El ANNUALLY p PER UNIT ❑ PER SITE d �aI i <br /> EACH ❑ January.1 8 Received By January 31 ❑ July 1 &Received By Juiy 31 } <br /> BASE i�l EXPLANATION BILLING REMITTANCE $ REMIT i <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE .v AMOUNT i <br /> LESS yq7 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ;II <br /> OTHER JI k <br /> Received.by. Date <br /> it Receipt No. Permit No. Ussuance ate- Mailed <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered is j <br /> :jf I Y 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />