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ApplicationsWill Be Processed When Submitted Properly C I to 9L� -r <br /> Ttf'Si��n TFie I ation. *T <br /> FOR OFFICE use: _ APPLICATIO Z`�J <br /> t (For Non Transterable,''Revocabl enVro 1979 <br /> L11 PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ) <br /> DGAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JOAQUIN L <br /> Application is hereby made to the San Joaquin Local Health District for a permittocanstructan� �1lth�DwSTRICT <br /> ork rendescribed.Thisapplicationis <br /> Sa <br /> made in compliance with Co my O:di5pK9e No. 1,862 and Xe rules and regulations of the San J In L c� H It strict. G <br /> Exact Site Address re 1/f <br /> City/Town 4 � <br /> Owner's Name 8,11LIr I' Phone 1^ <br /> I Address / 11,01 City <br /> Contractor's Name . License Business Phone <br />` Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation I surance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONS 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 Welly Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 0 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 0 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 Inst Iled By: _ <br /> PUMP INSTALLATION: } <br /> Contractor I <br /> ,,TT�,y,p�ee of Pump f P <br /> PUMP REPLACEMENT: Lu'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 dome 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 ttt <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 employ persons subject to workman's compensation laws of California." <br /> I will call 1 r t inspection prior to grouting and a final inspection. <br /> Signed _ Date: <br /> (Draw Plot Plan on Rev se Side) <br /> FOR DEP RTME USE ONLY <br /> PHASE <br /> Application Accepted By Dat <br /> Additional Comments: <br /> Phase II Grout Inspection P4ie III Final Inspection <br /> Inspection By Date Inspection By r Date —� <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT X PCR SITE ❑ EACH ❑ January I &Received By January 31 ❑ July 1 &Received By Jury 31 <br /> I <br /> RASE EXPLANATION $BILLING REMITTANCE - REMIT t <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE _ T.... • AMOUNT <br /> LESS 3J <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> nLAI <br /> --7 <br /> Received by Date Receipt No. Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALCCOPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES, 1501 <br /> E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />