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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR oFF1OE F_: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMA&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> k WATER QUALITY <br /> f (COMPLETE IN TRIPLICATE) <br /> Application is 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 in compliance with San Joaq ounty Ordinance No. 1862 and the ru s and regulatioks ff the San Joaquin Local Health District. pC <br /> Exact Site Address S� City/Town <br /> Owner's Name /l/ Phone IR, l d <br /> Address C b N FC 1-C City �✓, <br /> Contractor's Name u� !A^ License ff3�D�S/ Business Phone g� <br /> Contractor's Address O Crnergency Phone r f ! <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4____ No <br /> TYPE OF WORK (CHECK): NEW WELL Et---DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank t•Sewer Lines Pit Privy <br /> "Sewage Disposal Field (� - Cesspool/Seepage Pit Other - <br /> Property Line/ Private Domestic Well �Q.� Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation Cal (� <br /> 9'15OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing et—, <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal C) <br /> ❑ CATHODIC PROTECTION �iOTARY Type of Grout Uti� �` 4 <br /> ❑ DISPOSAL ❑ OTHER Other Information P, t <br /> ❑ GEOPHYSICAL urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. a/ <br /> i 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 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 /> I <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 /> i is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> S ermit is issued, I shall emplosons subject to workman's compensation laws of California." <br /> I 'It call for a Grou No t� routing and a final inspection. <br /> t <br /> Signed X Title: f cS_ !' C n r _ Date: d <br /> (Draw Plot Plan on Reverse Side) <br /> r <br /> r FOR DE ARTMEN USE ONLY <br /> PHASE I Q� O <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection Dale_ / ' Inspection By Date <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 AMOUNT <br /> FEEtU <br /> LESS <br /> PRORATION <br /> i PLUS <br /> 1 PENALTY <br /> { OTHER <br /> I OTHER <br /> 0. <br /> Received by Date - Receipt 00. Permit No, Issuance Date 'Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 160TE.HAZELTON AVE.,P.O.Bow 2009 ' STOCKTON,CA 9520 <br />