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Applicatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appli,cation. '* <br /> TR OSCE USE: APPLICATION" <br /> 9 (For Non-Transferable, Revocable,Suspendabie) ,PUMP&WELL <br /> ENVIRONMENTAL—HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY' t,t <br /> t Application is hereby made to the San Joaquin Local Health District for a permit to const ructand/or ins tall the work herein described.This application is <br /> made in compliance with San J aq in CountWancel4o. 186 and the ules and regu tions of the San Joaquin Local Health District. <br /> Exact Site Address /O54City/Town <br /> Owner's Name Phone <br /> Address ' ' i <br /> �/: - `,. City G r i <br /> Contractor's Name Q/ License# 17Business Phone <br /> Contractor's Address 5 $Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File WithJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL El EN' DEEP ❑ RECONDITION❑ DESTRUCTION❑ F}' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ - <br /> REPLACEMENT❑ "A <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 77- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL r { <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> V+IRRIGATION �. ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r <br /> ❑ DISPOSAL ! ❑ OTHER Other Information x <br /> ❑ GEOPHYSICAL ^,I Surface Seal Installed <br /> PUMP INSTALLATION: Contractor e4_1 . <br /> Type of Pump <br /> PUMP REPLACEMENT.- ❑ State Work Done <br /> PUMPOEPM; *State Work Done <br /> DESTRUCTION OF WELL: -Diameter x Approximate Depth <br /> Describe Material and Procedure qQ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r <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 forwhich this <br /> Y L permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> f <br /> I will call for a Grout Inspections--pri--prior to grouting and a final inspection. 7 <br /> g _ ' �• ' # <br /> Si ne X Title: - _ Date <br /> Draw Plot Plan on Reverse Side)' s " <br /> f <br /> FOR DEPARTMENT USE ONLY i <br /> Application AcceptedBy Date 1� <br /> Additional Comments: <br /> Phase Il Grout Inspection V Phas III Final Inspection//y�,,������ <br /> Inspection By Date Inspection.By Date /"'~,&7— � <br /> FCC Is Dile: ❑ ANNUALLY ❑ PER_UNIT' ❑ PER SITE - ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 i <br /> REMIT + <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE k <br /> t <br /> LESS <br /> PRORATION Y /'L r Je4y- <br /> PLUS <br /> PENALTY �•1`y vEd / h�C,/-4v C e-e?t t <br /> OTHER 0/• A1114 (,o G4ilC 4lt'rY i <br /> OTHER _ <br /> r <br /> Received by Date Receipt No. Permit No.. Issuan Dale_. Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />