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Applicatl V Process en Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ' It '\002(Fcir Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ,-� H PERMIT <br /> �ORONMENTAL HEALT <br /> (COMPLETE IN TRIPLI E) .� .� �R� WATER QUALITY <br /> Application is hereby made to the San I Health District fora permit to construct and/or install the'work herein described.This application is <br /> made in compliance with San JAS (ljp rlt Ordinance No 1862 an the rules and regulations of the San Joaquin L cal Health District. <br /> Exact Site Addres J City/Town <br /> Owner's Name IV I C-IQ A10 Phone <br /> Address i f'rL City <br /> Contractor's Name License A. ro <br /> Contractor's Address 2,Q p 14-6t Emergency Phong /1E <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes { No <br /> TYPE OF WORK (CHECK): NEW WELL❑" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTO I' <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 r Dia. of Weil Excavation <br /> EJR DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK —Depth of Grout Seal <br /> k ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 4 ❑ DISPOSAL ❑`OTHER Other Information <br /> L ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: .Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: State Work Done "Wi <br /> PUMP REPAIR: . - ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I herebq certify that I'have prepared this application and that the work will be done in accordance with San Joaquin County <br /> r ordinances, state laws, and rule`s 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 forwhich this <br /> permit is issued, i all employ persons subject to workman's compensation laws of California." <br /> I wi II for a t I ec n prior to grouting-and a final inspec o <br /> p Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> f FOR DEPARTMENT USE ONLY <br /> 4 <br /> t PHASE I <br /> Application Accepted B Date L� <br /> Additional Comments: <br /> Phase 11 Grout Inspection a III Final Inspection <br /> Inspection By— �n r Date Inspection By � Date <br /> !�5_ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER'UNIT ❑ PER SITE ❑ EACH ❑ January`s &Received By Januar ❑ July 1 &Received By July 31 <br /> REMIT <br /> € BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE r CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> . <br /> PLUS yy <br /> PENALTY <br /> OTHER <br /> OTHER a <br /> Received by Dae 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 />