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PcatiTVill B� roc seed A Submitted Properly Be SureToSignTheApplication. Kl <br /> FOR OFFICE USE: P IGO <br /> 2 <br /> „ (For Non-Transferable, Revocable,Suspendable) <br /> SAN 0,rkQWN L PUMP &WELL <br /> HEALTH DISTR�IRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaq=Cina o. 1662 and the rules and regulations of the Sanoayl}sin Local.Health Dist /'- <br /> Exact Site Address ` 0 aity/Town �-�l_R��d � v f2�1dt� <br /> Owner's Name Phone <br /> Address j city- <br /> Contractor's <br /> ity 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 h No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ -- <br /> REPLACEMENT❑ _ v j <br /> DISTANCE TO NEAREST: Septic Tank c*)® Sewer Lines Pit Privy QS <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 <br /> Type of Pump H.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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work torwhich 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 fall for a Grout Insp tion prior to grouting and a final inspection. <br /> Signed X Title: Date: q1.3 ZIS <br /> (Dra Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Q Date <br /> Additional Comments: <br /> -Ph e I Grout InspectionA Phase III Fin Inspection <br /> Inspection Date%-off Inspection By + '- Date <br /> Fee IS Due: ❑ ANNUALLY '1]-PERI9NTT'. ' ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> RILLENG REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �f AMOUNT <br /> FEE —4- I[ !3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered--A <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTO <br />