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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION /J <br /> (For Non-Transferable, Revocable}Suspendable) PUMP&WELL (/ <br /> ENVIRQNMENTAL-HEALTH PERMIT i <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY,,.-, *n,^I 's© c, <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work,her described This application is <br /> made in compliance with San Joaqui Cou Ordinance No. 1 62 and they rules and regulations of the SanrJoaqyln,Local Health District. <br /> } Exact Site Address �O U City/Town F T <br /> Owner's Name tv— Phone <br /> Address o c5 K& City'.' <br /> Contractor's Name License#�/ "2BusinessPhone:' <br /> Contractor's Address l J' r' Emergency Phone —�Co.•1,[., <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 13RECONDITION❑u _ -DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR ICI <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ��,tt Pit Privy s, <br /> Sewage Disposal Field Cesspool/Seepage Pit Other ) <br /> Property Line Private Domestic Well Public Domestic Well E <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑-DRILLED Dia. of Well Casing i s ni <br /> si <br /> ❑ DOMESTIC/PUBLIC' ❑;DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑;GRAVEL PACK Depth of Grout Seal --L <br /> ❑.CATHODIC PROTECTION ❑kROTARY Type of Grout <br /> I& ,. ! "•a ,.1y <br /> r <br /> _0'r DISPOSAL (IOTHER Other information <br /> ❑ <br /> GEOPHYSICAL:- - Surface Seal Installed By: 1. <br /> PUMP INSTALLATION: ' Contractor <br /> H.P. <br /> Type of Pump L <br /> PUMP REPCACEMENT: <br /> State Work bone <br /> PUMP REPA , .' <br /> IR: a ©'State Work Done , <br /> DESTRUCTION OF'WE 'Well DiemULU1 ___ Approximate'Deptfi <br /> Describe Material and Procedure <br /> hereby certify that I'have.prepared this application and that the work will be done m accordance with San Joaquin County :. h <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, tlrl <br /> ! <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of'thework 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 Californ w <br /> IIIIall rr5pectionjprior grouting and a final inspection: , <br /> Signed X itle: Date: ! <br /> (Draw Plot Plan on Reverse ide) t E <br /> FOR DEPARTMENT USE ONLY 7 > !� i <br /> PHASE I ; Y <br /> Application Accepted Byf``y�'~ �� �r ^-3 Date- <br /> - , <br /> Additional Comments: I <br /> Phase II Grout Inspection ,lPhase 111 Fina! Inspection <br /> Inspection By. Date Inspection By /"f eed Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT` - -❑ PER SITE ❑ EACH. -❑ January 1 8-Received 9y.lanuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> - - " -- BASE EXPLANATION - iBILLING _ - REMITTANCE .$ AMOUNT DUE CHECKED -� <br /> DATE DATE' REMITTED AMOUNT <br /> FEE f F <br /> LESS - <br /> PRORATION ~ ' <br /> PLUS ..- j IK— I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No, Is uance ate -Mailed ..Delivered` -SII. <br /> APPLtCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 9S201.' <br /> i <br />