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Applications Will Be Processed When Submitted ProperlyCompleted. Be-Sui Tjb;SikinTVhenpplicr. <br /> FOR OFFICE USE: APPLICATION �_ <br /> (For Non-Transferable, Revocable, Su Pe able) <br /> ENVI NMENTAL HEALTH PIIT PUMP&wFLL Y <br /> (COMPLETE IN TRIPLICATE)/ D WATER QUALITY , � } D�0- <br /> Application is hereby madetotheSa Joaquin Lo ealthDistrict fora permit toconstruct and/ofMrp"�'��l dieryoek6ijr?j"L Cribed.Thisapplicationis <br /> made in compliance wit oa in unt dinance No. 1 2 a t rules a regulations c}f}t!] � aquin Local al tri t. <br /> Exact Site Addres City/Town <br /> Owner's Nam Phone77 <br /> Addressa City <br /> Contractor's icense# a Busln Phone ! <br /> LI <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❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 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 Liner Private Domestic Well Public Domestic Well - <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL -- H ❑ CABLE TOOL - - 4 Dia. of Wel! Excavation-^�= - <br /> ❑ 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 <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter - Approximate Depth <br /> Describe Material and Procedure 1,f <br /> u <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 Heal th'District. i <br /> Home owner or licensed agent's signature certifies the following:"i certify t in the pertormanceof thework forwhich this permit _ <br /> is issued, I shall ploy any person in such manner as to bec ubject to workman's compensation laws of California." <br /> Centra Ir' g or uh-contr signature certifies the Poll i :"i certify that in the performance of the work for which this <br /> per It i is d, 1 s II empl perso s subject to workman's pens n laws of California <br /> I ill c r s e pri and a fin. sp f <br /> Signed X <br /> Title: Date: <br /> (Draw Plo Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY t. <br /> PHASE I <br /> Application Accepted By �1X9�.. � Date <br /> t <br /> Additional Comments: <br /> Phase+ll Grout inspection / R"FinalionInspection By_M lr. Date Inspection By ;"� aFee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January,1 &Received 1 &Received By July 31 <br /> REMIT <br /> BASE i' EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS I� <br /> PRORATION " <br /> PLUS r' } <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER I <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered ��l/��-� <br /> APPLICANT.—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE._,P.O.11 2009 STOCKTpN,L'YY95201 <br />