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( Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> Fcn of BICE usl=: APPLICATION ' <br /> (For Non-Transferable, Revocable;Suspendable) PUMP &WELL <br /> y ENVIRONME:N7AL HEALTH-PERMIT <br /> r (COMPLETE IN TRIPLICATE) WATER QUALITY <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 San Joaquin Cou ty Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town t1 } <br /> I Owner's Name Phone' <br /> Address City <br /> IContractor's Name License# L� Business Phone-46 <br /> k Contractor's Address &-61 a1�L 'Emergency Phone 1 <br /> I 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 /> REPLACEMENT❑ J <br /> I r - <br /> DISTANCE TO NEAREST: Septic Tank Sew er Lines�� —� Pit Privy <br /> Sewage Disposal Field f0 "E Cesspool/Seepage Pit --- Other <br /> Property Line,ZO Private Domestic Well c:!�n ::t 'Public Domestic Well - <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ElCABLE TOOL Dia. of Wall.Excavation- <br /> 4 <br /> xcavation <br /> pkDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ` ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION IRGRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout N <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: d2i/ACA w <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump H.P. y <br /> PUMP REPLACEMENT: ❑ State Work'Done �►ai <br /> PUMP REPAIR: ❑ State Work Done vu <br /> ,k 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 for which this <br /> permit is issued, I shall#nploy persons subject to workman's compensation laws of California." '7h <br /> I I tail 1 r r I spection riot to grouting and a final inspection. <br /> Signed Title: k _� ........ Dale: <br /> (Draw Plot Plan on Reve r Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �1 <br /> Application Accepted By Date ° UC71- <br /> Additional Comments: <br /> Phase II Grout Inspection Pas Ill Final Inspection <br /> Inspection By Date - lnspection By Date + <br /> Fee Is Due: ElANNUAL'LY '❑ PER UNIT [3PER SITE ElEACH ❑ January 1 &Received By January 31 El July 1 &Received By July_31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> 'v DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER , <br /> ' OTHER <br /> Received by Dater - Receipt No. Permit No. `fes Issulance O te. Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />