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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SigFI Application. 198,v jj [) <br /> FOR OFFME USE: APPLICATION SEP 24 �jr�f� <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL'HEALTH'"PERMIT SAN HAQUf <br /> (COMPLETE IN TRIPLICATE) �_ OCAL <br /> WATER QUALITY HF��J0j� DIST-RICT <br /> Application is hereby made to the San Joaquin Local Health District for a permitto cohstruct and/or install the work herein described.This application is <br /> made in compliance with S n Joaquin County Or aoA".o1862 and the.rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address [!il j City/Town ��L ��[)`� 5 <br /> Owner's Name Phone ` <br /> City <br /> Address - ` <br /> Contractor's NameiV <br /> 4"L License#mi <br /> NC <br /> business Pho e"1 <br /> Contractor's Address '' +Emergency Phone w- ~� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ <br /> TYPE OF WORK"(CHECK): }'NEIN WELL DEEPEN ❑ "RECONDITION❑ DESTRUCTION❑ — _ <br /> WELL CHLORINATION WELL ABANDONMENT.❑ "OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: a Septic Tank! + Sewer Liries Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> iPOEOPHYSICAL, <br /> DED USE TYPE OF WELL <br /> RIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> TIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> TIC/PUBLIC } ❑ DRIVEN Gauge of Casing <br /> TION -❑ GRAVEL PACK Depth of Grout Seal <br /> DIC PROTECTION ❑ ROTARY Type of Grout <br /> AL ❑ OTHER Other Information <br /> l : <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> c ump H.P. <br /> 11, <br /> PUMP REPLACEMENT: tate Work Done <br /> ❑ State Work Done w t ' r <br /> PUMP REPAIR: <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> y 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 J"oaquin 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:1 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 /> f permit is issued, 1 shall employ persons b'ect to workman's compensation laws of California." <br /> ill c for a Grout Inspec -prio grou and a final inspection. <br /> Signed X a•� Title: t Date: <br /> ? (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By T <br /> w � Date <br /> Additional Comments: ` <br /> Phase II Grout Inspection Phase Ill Final Inspection <br /> 'Inspection By Date Inspection By A- Date 6 <br /> U. Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & ceived By January 31- ❑ July 1 &Received By July 31 <br /> REMIT <br /> .BILLING REMITTANGE AMOUNT DU£ CHECKED <br /> ! BASE '' r EXPLANATION DATE DATE REMITTED AMOUNT <br /> 134 FEE f t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> OTHER <br /> Received-by — Date '` - Receipt No. ---Permit No - — "I suanc Dat _Mailed' Delivered" <br /> STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO:, ENVIRONMENTAL HEALTH PERMIT/SERVICES 1641 E.HAZELTON AVE.,P.O.Box 2009 <br /> S <br />