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- iil Be Processed When Submitted Properly Completed. BSUM To Sign The Ap ion. -- <br /> FOR oFFwr� APPLICATION (� f 1 ]S]c� <br /> (For Non-Transferable, Revocable,SuMVagle) J <br /> ` 'V JOAQUIN PUMP&WELL <br /> .1 ENVIRONMENTAL HEALTH P LT-N <br /> LOC <br /> (COMPLETE IN TRIPLICATE) 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 Qounty Ordinance No. 1$62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �� tY1,+-er> 1�CrGt-.sem, City/Town � ca- <br /> Owner's Name Phone 2 <br /> Address City <br /> Contractor's Name J License#`Z Business 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❑ Q <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> t 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 /> r © DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> r ❑ 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 r Surface Seal Installed ByT <br /> PUMP INSTALLATION: Contractor I'1 4- , . it, <br /> Type.of Pump H.P. �l <br /> PUMP REPLACEMENT: CR State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL:_ Well Diameter Approximate Depth <br /> = w 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 /> E' 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 /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." fW,_q.D <br /> I will call for"Lit Inspection prior to grouting and a final inspection. �T1 4- <br /> Signed <br /> ► Signed X G�8'rG? -� Title: .y�a.�.� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> R D ARTMENT SE ONLY <br /> PHASE I <br /> Application Accepted By Dat T <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ,: © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedByJuly 31 <br /> REMIT <br /> BILLING REMITTANCE - $ <br /> BASE ' EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �J AMOUNT <br /> FEE Y�s� C <br /> LESS - <br /> PRORATION <br /> ' PLUS <br /> PENALTY JA - <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Dae Mailed Delivered <br /> f <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95- 2U <br />