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A Applications Will Be Processed When Submitted Properly Completed.Be-ScitiSfVd The Application, T <br /> FeR oF�jcE:USE, APPLICATION ; 12' J <br /> (For Non-Transferable, Revocable,Suspen�} PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SEP 14 1981 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/orw <br /> it � orK,iierein.descr.bed.This application is <br /> made in compliance with San Joaquin C untyf�dinance No. 1062 end t e rules and regulations of� nlJ a uin Loc I Health District. <br /> Exact Site Address_. �i 7 � r ,�,s� P City/Town <br /> . -, <br /> Owner's Name/�,� �-f ��� ��� - Phone S' 7 �- <br /> Address O ,� <br /> + City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address " Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy t� <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 k Dia. of Well Excavation l <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Wel! 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 <br /> Su ce Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> 4 <br /> yd <br /> Type of Pump T' H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: R-State Work Done <br /> DESTRUCTION OF WELL:} yv Well Diameter <br /> r ► Approximate Depth <br /> escribe.Material.and..P_rocedure --- <br /> I hereby certify that I have prepared this application and that the work will'be done in accordarice 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 7 <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 su b-contracting signature ce` ifies the following:"!certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject tdworkman's cdmpensaton Ilws of California." <br /> I will II to_r a Grout Inaction prior ting and•a-final-inspection. 1 <br /> Signed X <br /> ,-� . Date: <br /> (Draw Plot Plan on Revers ide) 4 <br /> 1 F,OR DEPARTMENT USE ONLY <br /> PHASE I ". - <br /> Application Accepted B { Date <br /> Additional Comments <br /> Phase 11 Grout Inspection �f. ' � hale Ill Final Ins action <br /> Inspection By Date 4. In pection By l pate /a g S/ <br /> 1 <br /> Fee IS Due: 11 ANNUALLY ❑ PER UNIT. C1 Pi SITE ❑ <br /> EACH" ❑ January 1 &Received By January 31'. ❑ July 1 &Received By Juiy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> (3i + <br /> FEE t}� �.. <br /> LESS <br /> PRORATION t <br /> PLUS <br /> t <br /> PENALTY <br /> OTHER <br /> OTHER 'N11 <br /> ' c <br /> Received by Date ' <br /> Receipt No. Permit No. -Iss-once D to - Mailed - Delivered r <br />"` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 + <br />