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�.. - � <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT I/ 1-29—_,• <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) l <br /> Application is hereby madeto the San Joaquin Local Health District f a ermit to constructand/or install the work herein described.This application is <br /> made in compliance w'th San Joaquin o y r mance N�� the r jnd regulations of the Saoaquin Local Health District. <br /> Exact Site Address /�'"' City/Town <br /> r <br /> 1 <br /> Ownee's'Name Phone. ` <br /> Address City <br /> Contractor's Name License Business Phone',t <br /> Contractor's Address '- 'Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ { <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 - RECONDITION 13 DESTRUCT <br /> ION❑= - v <br /> WELL CHLORINATION El WELL ABANDONMENT 11 OTHER ❑ . PUMP INSTALLATION. PUMP REPAIR❑ <br /> REPLACEMENT❑ , <br /> DISTANCE TO NEAREST: Septic Tank i Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 1 '"Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑�DDOMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing <br /> �,, <br /> P�DC0MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surf a Se I Installed By:; <br /> PUMP INSTALLATION: Contractor <br /> 67 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that l 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 ti <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> k: <br /> I will c r Grout Insp.ction prior to grouting and a final inspection. <br /> Signed <br /> Title: It�^ l Date: - t <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /i// pate <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph anal Inspection <br /> Date Inspection B Date <br /> Inspection By . <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' © PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED j� AMOUNT <br /> I EE <br /> LESS <br /> PRORATION <br /> PLUS ;r <br /> w PENALTY 'f <br /> a OTHER <br /> OTHER <br /> ` Received by Date Receipt No. Permit No. _ ___ Is ante ate Mailed Delivered _ I <br /> F APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />