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ApplW a,ion t 4WBe Processed Wh,L milted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: L (]AA APPLICATION <br /> .N DEC 3 WNon-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> SAN <br /> JO,"QUINENMIA-0-NMENTAL HEALTH PERMIT <br /> f <br /> (COMPLETE IN TRIPLICATE) HEALTH plSTWCT WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application_ is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin o alb lealth District. <br /> Exact Site Address 1` City/Town ✓! <br /> Owner's Name p I <br /> Phone <br /> Address u <br /> ity _ , <br /> Contractor's NameLicense# s' ss Ph nye/ — } <br /> Contractor's Address Emergency Phone �t �'T ^ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK):" NEW WELL❑ DEEPEN ❑ RECONDITION C1 -DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION 11PUMP REPAIR I11� <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 t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL Cl OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: rr❑,t Sl�tate Work Done <br /> 0► <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 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call fora G ut inspection prio grouting an a final in 9clion. �� �/ d <br /> Signed X I Date: <br /> (Pr9wJk0Ia9,6n Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By GLAaC,. -Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha a III Final Inspection 7 <br /> Inspection By Date Inspection Bye <br /> Fee Is 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 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED. AMOUNT <br /> FEE, <br /> LESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by DateReceipt No. Permit No. - _ 'Issuanc Date. Mailed .Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 f <br />