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Applications Will Be Processed When Submitted Properly Completed. BeTAig The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) U <br /> ENVIRONMENTAL HEALTH PERMIT PUM ELL <br /> 4 5AN ���,��tN L{�G�� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DIST <br /> RgCT � <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance ith San Joaquin Cou t 0 dinance N 862 and the rules and re ulations of the San J uin al Health District. <br /> Exact Site Address q y g City/Town h <br /> Owner's Name Phone <br /> Address illCity <br /> Contractor's Name License# Busin ss Phone ; <br /> Contractor's Address Emergency Phone 1-/b34ofl--z- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION[] I <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/Sgepage Pit Other <br />± Property Line Private Domestic Well S50 Public Domestic Well ; <br /> INTENDED USE TYPE OF WELL <br /> ❑,,INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> q <br /> t 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 /> i ❑ GEOPHYSICAL Surfac Seal Installed By: <br /> I PUMP INSTALLATION: Contractor �I <br /> i Type of Pump H.P.— <br /> PUMP REPLACEMENT: ❑ State Work Done Ill <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:1 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 /> 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 II fora u1 spectian prior to grouting and a final inspection. f' ��� <br /> Signed A Title: T;AJa`t`(JIJVI_e4— Date: <br /> (Draw Plot Plan on Reverse Side) <br /> 7770 <br /> ENT USE Y <br /> PHASE 1 <br /> Application Accepted By Date " <br /> Additional Comments: <br /> i <br /> Phase II Grout Inspection a fl Final Inspection <br /> Inspection By Date Inspection By Date 7- <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 /> ASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED i <br /> AMOUNT <br /> FEE <br /> I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER I <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 9520 <br />