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ti{ p i ons W Be Processed " Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: 3 A993 APPLICAVON <br /> (For Non-Transferable, Revocable, Suspendabie) PUMP&WELL <br /> JCA u;t4 L MONMENTAL HEALTH PERMIT <br /> Db WATERUALITY <br /> (COMPLETE IN TRIPLICATEt �s. Q r <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 an Joa uin C unty Qrdinancp No. 1862 and the rules and regulations of the San-doaquin Local Health District. <br /> Exact Site Address © City/Town <br /> r Phone <br /> Owner's Name <br /> Address rOf City y <br /> cc License# Business Phone— <br /> Contractor's <br /> hone�- <br /> Contractor's Name <br /> *� <br /> - ' ' .:: Emergency Phone <br /> Contractor's Address _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4� No <br /> TYPE OF WORK (CHECK): NEW WELL ElDEEPEN ❑ RECONDITION 11DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ „_ - .__1 - <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 /> ❑ IRRIGATION ❑ GRAVEL PACK" Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 4a State Work Done a <br /> ^J <br /> DESTRUCTION OF WE tL: Well Diameter <br /> 9 r' Approximate Depth <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 /> Home owner'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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r <br /> I will Fall for rout Inspection prior to grouting and a final inspe n. <br /> Signed X L" Title: .� Date. <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY - f <br /> PHASE I _ Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phas ut Inspection /Phase Ill Final Inspection <br /> Inspection By Date Inspection ByVlDate �- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑ January 1 &R2ce!Ve.d By January 31 ❑ July t &Receiv REMITuIy 31 <br /> ` -- .91LLING .REMITTANCE $ - AMOUNT DUE <br /> BASE EXPLANATION CHECKED <br /> t I DATE DATE pREMITTED AMOUNT <br /> O <br /> FEE -S, <br /> LESS * 3 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -} <br /> Received by Oat Receipt No Permit No. - Issuance Date Mailed Delivered <br /> 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 96201 <br />