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ApplicationsWill BeProcessedWhen SubmittedProperlyCompleted. <br /> Be ureT�NSiApplication. <br /> FOR-OrFICE USE: APPLICATION <br /> (For Non-Transferable, Revocabl S spe ble) <br /> �44`-,,p ISON <br /> PUMP&WELL <br /> ENVIRONMENTAL H TI PERM1� <br /> (COMPLETE IN TRIPLICATE) WATER QUAJ �� �G <br /> Application is hereby made tothe San Joaquin Local Health District fora permit to c ructand/orinst&ljt�le`mrd'&Kereindescribed.This application is <br /> made in compliance with San Joaquin County Ordinance62 and the rules and regulations$ n Joaquin Local Health District. <br /> Exact Site Address <br /> Owner's NameDN.- ��arc/ Phone <br /> Address City. <br /> Contractor's Name License# ���3�-3 Business Phone e �'./ 1 S cz <br /> Contractor's Address ' Emergency Phone <br /> 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECOND ON❑ DESTRUCTION El �r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER Ef PUMP INSTALLATION ❑ 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 Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I=I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ 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 Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done�i_11�;00P , <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure f h <br /> �1 <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 /> Home owner or licensed agent's signature certifies the following:"i certify that in the performance of the work forwhich 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 shall employ persons subject to workman's compensation laws of California." <br /> I will <br /> ,,call <br /> ��for a Grout Inspection prior to grouting and a final inspection. 1) J <br /> Signed X GGNIt tJt.e�z.I` P Title: Date: �3 I <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date ' <br /> Additional Comments: <br /> Phase II Grout Inspection ase III Final Ins ection <br /> Inspection By � �,_ Date Inspection By 77—+e Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT pUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER G q <br /> Received by Date Receipt No. Permit No lsduanc6 D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />