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Applications Wili Be Processed When Submitted Properly Completed: BeSure.T0sign IneKIJIJIR wrr• <br /> APPLICATION <br /> FOR OFFICE usE: I <br /> { (For Non-Transferabie', Revocable Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH;PERMIT <br /> ! WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) 11 ,r"+ f" <br /> Application is hereby made to the San Joaquin Local Health Districttor a permit to construct and/or install the work herein described.This application is <br /> made in compliance wit/h�San Jo quip County Ordinance No. 1862 and the rules and iegulations of the San Joaquin Local Health District. <br /> �Ir� t City/Town <br /> Exact Site Address f <br /> IR Phone <br /> Owner's Name " <br /> City <br /> Address ' l `� Business <br /> Phone <br /> Contractor' Emergency Phone <br /> s Name License <br /> p .` 1 <br /> Contractor's Address � L- No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK)-' ` NEW WELL"❑ DEEPEN ❑ RECONDITION❑ ' DESTRUC710N�❑im_MP REPAIR❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER.❑ _ PUMP INSTALLATION Li <br /> REPLACEMENTOf__F' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other c. <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND RIAL I E] CABLE TOOL - Dia. of Well Excavation <br /> OMESTIC/PRIVATE <br /> �I ❑ DRILLED Dia. of Well Casing <br /> DRIVEN <br /> 11 DOMESTIC/PUBLIC ❑ Gauge of Casing�!; -� <br /> ❑ IRRIGATION M1 ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL 11OTHER Other Information <br /> E] GEOPHYSICAL d Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:, !I ❑ State Work Do <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ; <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> I hereby certify that If have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law", 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 orEsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this i <br /> ., persons subject to workman's compensation laws of California.' <br /> permii: is issued, I shall employ p i •- <br /> I wllf ca a.Grout;ln ectlon.prior to grouting and a final inspection. , <br /> t � Title:. Date:.f�� <br /> (^ Signed X._ <br /> (Draw Plot Plan on Reverse Side) �. <br /> FOR DEPARTMENT USE ONLY <br /> � PHASE I • IH�� s f � - <br /> �j. Date <br /> Application Accepted By,II- . <br /> p Additional Comments: nal Inspection <br /> Phase ll <br /> �Grout Inspection <br /> Inspection.By �! Date. <br /> Inspection By Date <br /> I. <br /> i <br /> "frFee,IS DUe:'❑ ANNUALLY".@ ❑aPER UNI 7` PEA-SITE ❑ EACH C1January# &Received By January 31 ❑ July# &ReceiveR MITuly 31 <br /> c !I rBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> 'LESS r <br /> PRORATION <br /> PLUS ' - <br /> F PENALTY r I <br /> ` OTHER " <br /> OTHER <br /> ' - -Date �._ Receipt No. _ '; Permit No. _ seance D to _ Mailed Delivered <br /> Received-by <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT15Eri4lCES 1601 E.HAZELTON AVE.,P.O.80><2009 STOCKTON,CA 95201 <br /> �I. <br />