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A ations Will Be Processed ubmitted Properly Completed. Be Sure To Sign The Application. <br /> Flc <br /> FOR oFUSE: AUG 1982 APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> SAN c)_.QIUINONMENTAL HEALTH PERMIT <br /> DISTRICT <br /> (COMPLETE IN TRIPLICATE)HEALTI~I WATER QUALITY <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 Joaquin C unty Ordinance No. IA62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address-&-.f-S(, City/Town <br /> Q—I <br /> Owner's NamePhone <br /> Address � City h2 <br /> Contractor's Name License# p� �X� Business Phone <br /> Contractor's Address -°a' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR81r <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 <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 /> 44 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PR TECTION ❑ ROTARY Type of Grout <br /> a DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. S <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth n <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wit call for out Inspection prior to grouting and a final inspecti �f , <br /> Signed Xel. � Title: � +�-r- Date: � <br /> (Draw Plot Plan on Reverse Side) 1. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I `^1^e,,• 4 <br /> Application Accepted B "�`—Q� Date "tea^ <br /> Additional Comments: <br /> Phase II Grout Inspection s 111 Final Inspection <br /> Inspection By M Irt Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 1 3 <br /> Received by Date Receipt No. Permit No. lsfuancI5 Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />