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- � A p ications WiIL.Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR.,OFFiE USE: f � APPLICATION <br /> lam- ../ (For Non-Transferable,'RerlScable Suspendable} PUMP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT <br /> . - WATER QUALITY ,, h is <br /> �; � � �.+. n <br /> (COMPLETE IN TRIPLICATE) <br /> t Application is hereby made to the San Joaquin Local Health Districtfora permit toconstructand/or install the work herein described.This applicatio <br /> �,, r ..� ' <br /> 1. made in compliance with San Joaquin County Ordinance No. 1862 and he rules and regulations of the San Joaquin Loal. Health District. <br /> ••°{:_ City/Town ., <br /> Exact Site Address a �' <br /> .3 Cl <br /> Owner's Name i �S< .. I �i` .,v . �.� t Phone <br /> Address <br /> 6.C1�► .:. IZZ City .. t <br /> Contractor's Name e License# 16& 70 57'Business Phone} v" {i;nw t " <br /> Contractor's Address a - Q Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ HD? YesNo _ p <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTIONEI"=—'_ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER-0PUMP INSTALLATION ❑ PUMP REPAIRI <br /> } REPLACEMENT❑ I! <br /> 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 /> S IRRIGATION .11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> t ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION- Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done. <br /> °D <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter— ; <br /> Describe!Material and Procedure o <br /> 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 /> Homeowner 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 /> n r <br /> Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> r permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> II 'l call for a Grout Inspection prior to r0uu nd a final inspection. <br /> id in o <br /> Signed itle: Date: <br /> 1 (Draw Piot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> �.,,. <br /> Application Accepted By bate <br /> Additional Comments: ` ' <br /> iPhase 11 f Inspection has I��i al nVg4 Date Inspection Bye _-- <br /> Inspection By I <br /> Fee"IS Due: ❑ ANNUALLY' PER UNIT' 0 PER SITE EACH! ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT i <br /> - ,BASE` EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> FEE - j- <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY I <br /> OTHER <br /> OTHER i- c <br /> Received by - Date - - Receipt-No - - Permit No. - — - 'Issuance Date. - -- Mailed- - Delivered - --- <br /> APPLICANT—RETURN ALL COPIES TOS ENVIRONMENTAL HEALTH PERMIT/SERVICES 116011 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201.' <br />