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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign plication. <br /> FOR OFFICE USE: APPLICATION t <br /> (For Non-Transferable, Revocable,Stespelaj�� a. ! <br /> q �. t�1 PUMP&WELLENVIRONMENTAL HEA NIIT <br /> COMPLETE IN TRIPLICATE WATER QUALIT r <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstic and/bYQstabhey�ark�€ i��escribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations otrtl� �RXQocal Health District. <br /> Exact Site Address t' I.) <br /> Y� <br /> Owner's Named Phone IP <br /> Address City 7 <br /> Contractor's Name License#� _x,3_)_3 B1usi�ness Phone_ <br /> Contractor's Address 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 REPAIR <br /> REPLACEMENT❑ t <br /> 1 <br /> DISTANCE TO NEAREST: Septic Tank "Sewer Lines Pit Privy <br /> Sewage Disposal Field a ' Cesspool/Seepage Pit Other <br /> Property Line Priva a 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 Y <br /> IRPSTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY -;"Type of Grout <br /> © DISPOSAL © OTHER 4 ""` Other Information <br /> i <br /> © GEOPHYSICAL ` }' _S rface Seal Installed By: t <br /> PUMP INSTALLATION. Contractor r <br /> .Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ` <br /> PUMP REPAIR: 0'State Work Done es _ Y-- <br /> DESTRUCTION OF WELL: Well Diameteir Approximate Depth U13 <br /> Describe Material and Procedure <br /> 77 <br /> I hereby`cer-tify 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 arid regulationsof the San Joaquin Local Health District. <br /> Homeowner or licensed-agent's signature certifies the following."I certify that in the performance of fhe 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," i <br /> I will 1 fo a Grout I ection prig to grouting and a final insp Ian. / <br /> Signed X Title: Date: <br /> ;� (Draw P o non Reverse e} , <br /> { —FOR-DEPARTMENT USE ONLY-- � r <br /> PHASE I NA__ <br /> �! <br /> Application Accepted By Date�_"4- <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph I inal I ection i <br /> Inspection By a pate Inspection By Date p <br /> Fee is Due: El ANNUALLY El PER UNIT' ❑ PER SITE El EACH 1:1 January 1 &Received By January 31 ❑ July 1 &Received By July 31 j <br /> REMIT + <br /> BILLING REMITTANCE $ ! <br /> BASE EXPLANATION AMOVNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �O� AMOUNT <br /> FEE ��— <br /> LESS s <br /> PRORATION 1 <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER 1 <br /> Received by - Date Receipt No. Permit No. - Issua ce Date Mailed Delivered <br /> .. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES "1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />