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Applications*111 Be Processed When Submitted Properly Completed.BeSureToSignTheAppllCar"on. <br /> , w " <br /> :FORaOFFiCE USE: � "`�-' APPLICATIONS <br /> (For Non-Transferable, Revocable,' n I <br /> --.ENVIRONMENTAL F1�yP► <br /> �M PUMP&1IArn y <br /> (COMPLETE IN TRIPLICATE) WA v to <br /> YQ . <br /> Application is hereby made to the San Joaquin Local Health District r+�' constr t rinstallthework herein described.Thisapplication is <br /> made in compliance with San Joaquin County Ordinance No. 186 he rules���na pe ulations ;K1 8an J aquin Local Health District. <br /> Jr U�] c T'An <br /> Exact Site Address <br /> Owner's Name one <br /> s , N CityA. <br /> Address C <br /> Contractor's Name License# - Business Phone „- <br /> Contractor's Address Emergency Phones <br /> is Certificate of Workman's Compensation l surance on File With SJLHD? Yes o� No 1 <br /> 11RECON <br /> DITION❑ DESTRUCTION <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN <br /> I[ kA <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP R AIR <br /> f � <br />` REPLACEMENT❑ <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 c <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 1 ❑ 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 /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑,State Work Done <br /> PUMP REPAIR: <br /> estate Work DoneN <br /> 1 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 /> 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 /> 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 grouting and a final inspection. <br /> Signed X .Title: OJtI __ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEP TMENT USE ONLY <br /> PHASE I /�j '010 <br /> Application Accepted By v Date <br /> Additional Comments <br /> Phase 11 Grout inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <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 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED A NT <br /> FEELESS <br /> PRORATION <br /> PLUS 4-- ./YG✓ r <br /> PENALTY - <br /> OTHER <br /> < OTHER <br /> G <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 STOCKTDIV,CA 95201 <br />