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AppiiC t AWiil Be Processed When fitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: JUL " G 1'982 APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) .PUMP&WELL <br /> SAH iOf"WWN4IW4111IMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) HEATDISTRICT <br /> WATER QUALITY <br /> Application is hereby madeto 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 Coun y Ord' nqe No. 1862 and the rules and regulations of the San oaquin Lo I Health District. <br /> Exact Site Address ,�SCity/Town <br /> Owner's Name _ Phone <br /> Address City® <br /> Contractor's Name f License# Business Phone <br /> Contractor's Address Kd Emergency Phone \ <br /> Is Certificate of Workman's Compensation Insurance ori file With SJLHD? Yes I� No W <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 <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 4 r, T , ,'c-- <br /> Type <br /> c-Type of Pump <..SH.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: • Well Diameter 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 /> 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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed XTitle: Date: <br /> (Draw Plot Plan on Rever` Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted 13 0,0 Date <br /> Additional Comments: <br /> Phase II Grout Inspection P s III Final Inspection �� <br /> Inspection By, t� 1�_� Date Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <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 /> ��-- <br /> Received by Cate Receipt No. Permit No. Issuance 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 /> r <br />