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{ Applications Will Be-Processed When Submitted Properly Completed. Be Sure To S�n aanon. <br /> FOR WFICE USE: APPLICATION \�( <br /> (For Non-Transferable, Revocable, S p u <br /> �� ZIT <br /> PUMP&WELL <br /> ENVIRONMENTAL HEAL.TM+P �Q <br /> (COMPLETE IN TRIPLICATE) X. <br /> WATER QUALITYy1'u NQV �9 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thewq�W scribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulation of toetaai �> IMq ai Health District. <br /> Exact Site Address,��&S ��--- �,�+ � ^�-�^- - �t�, ' Cam <br /> Owner's Name Phone <br /> Address S City <br /> Contractor's Name License# /�a 323 Business Phone_rf <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No Q <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 67 PUMP REPAIR El y <br /> REPLACEMENT❑ <br /> UJ <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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Ty e of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f <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 groutiing and a final inspection. <br /> 4 14 ) �7 <br /> Signed X C� _1t�..r r�s 0 Title: -77my .tk ts/ Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY- <br /> PHASE I /^TS ��� <br /> Application Accepted By off Date <br /> Additional Comments: <br /> Phase EI Grout Inspection Phas III Fina Inspection <br /> Inspection By Date Inspection Date <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Rec fed y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTpN,CA 05201 , <br />