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ApplicationsWill Be Processed When Submitted Properly Cond. -Sure To Sign The A 1 tion, <br /> !71 <br /> APPLICATION bEC Z 1979 J <br /> (For Non-Transferable, Revocable, Sygendable) -� <br /> 9AN PUMP&WALL <br /> ENVIRONMENTAL HEALTH P�� 4�AQ�lN LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER-QUALITY lDi"S7-RICT (>� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Thisapplicationis <br /> made in compliance wit q Cxty--Qrdinanc No. 1862 and the rules and regulations of the Sa JoaSuiinn Lo� IW- aith District. l <br /> Exact Site Addres fJ� City/Town �T�`"�`-� - <br /> Owner's Name �- Phone <br /> Address 5,3y City erg <br /> Contractor's Name L� DP's License #/ Wa Business Phone 7 _ <br /> Contractor's Address. Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ,�firr <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR IA. <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 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 F <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Com, <br /> ❑ DISPOSAL ❑ OTHER Other Information y <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done AAm -�' <br /> PUMP REPAIR: Lflbtate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth fi <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." I <br /> Contracto ' ing or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this i1 <br /> P sued, I sh em y persons subject to workman's comp e sation laws of California." <br /> I Grout I pec on prior to gr uling and a final in *n. <br /> .�J + <br /> Signed - - Title Date: ��/// <br /> (Draw Plot Plan n Reverse Side) <br /> FOR DE ARTMEN USE ONLY <br /> PHASE I <br /> Application Accepted By �~ Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase II Final inspection <br /> Inspection By ", _ Date Inspection By __ ate <br /> Fee 1S Due: ❑ ANNUALLY ❑ PER UNIT. PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED j <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION " <br /> PLUS f <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> 1)�'4>,V "7 � <br /> Received by Date Receipt No. Permit No. - issuance ate Mailed Delivered F <br /> 4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />