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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Nan-Transferable, Revocable, Suspendabte) / i <br /> PLUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMP{�TE IN TRIPLICATE) NE,e/D6� /7�-�` WATER QUALITY <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 irkcompliance with San J q County Ordi n e No. 1862 and the rules and re �tiiOn�s, the an o quip Local Health )i r t. <br /> Exact "e Address /" ri'L- y <br /> Owner's Name Phone <br /> Address <br /> City <br /> Contractor's Name License# VAQ 9/3 Business Phone 1_ <br /> Contractor's Address Emergency Phone / <br /> Is Certificate of Workman's Compensationnsurance on File With SJLHD? Yes_ X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL, ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ J <br /> DISTANCE TO NEAREST: Septic Tank /00 Sewer Lines Pit Privy <br /> Sewage Disposal Field COQ 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 /> ,141 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing '14 O1,ua,66 ; <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 15e <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: 11 State Work Done <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 /> Home owner 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t <br /> Iw;IIC11 for a Grout Ir ction for to grouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw PI Plan on Reverse Side) V ' <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date-- <br /> Additional Comments: 1 <br /> P s Grout Inspection z2 Phase III Final Ins ection <br /> Inspection ByA/7= Date +�',L Inspection By te <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 /> BASE EXPLANATION BILLING REMITTANCE AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE L4 <br /> is <br /> LESS i <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received I DPW I Receipt No Permit No. Issuance Date Mai ed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 ,- <br />