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sippucanonswiu seProcessedWhen Submitted Properly Completed. Be S�o�g�heiApplicatio� <br /> FOR OFFICE USE: APPLICATIONUU <br /> (For Non-Transferable, Revocable,Suspendable) AUG 2 21983 <br /> t ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JOAQUIN LOCAL <br /> HEALTH C31�1iRiCT <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 with San Joaquin C unty Ordinance No.1 2 and the rules and regulations of the San Joaquin L cal Health District. <br /> Exact Site Address Ci y L,(� Cit <br /> n� City/Town - <br /> Owner's Name 1C Phone <br /> Address <br /> ti city—)714, �< a <br /> Contractor's Name License# Business Phone 2. <br /> Contractor's Address 9y Irl Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes i-- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 02-' 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 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 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r ce Seal Installed By: + <br /> PUMP INSTALLATION: Contractor <br /> T pe of Pump H.P. 1 <br /> PUMP REPLACEMENT: 4tate Work Done_- <br /> PUMP REPAIR: "0 State Work Done V uV <br /> DESTRUCTION OF WELL: W611 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 of4he work for which this permit <br /> is issued, I shall not employ any person in such manner as),o become subject to workman's compensation laws of Califorriia," <br /> Contractor's hiring or sub-contracting signature certifies the•foll'owing:"I certify that in theformance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of Calif a."4 <br /> I will call Piralroul Inspection prior to grouting and a final inspection: . <br /> Signed X Title: `L-. <br /> v;, Date: <br /> (Draw Plot Plan on Reverse Side) 1.► y. <br /> FOR DEPARTMENT:USE ONLY <br /> PHASE I <br /> Application Accepted By Date (� Z•3 i. <br /> Additional Comments: <br /> Phase II Grout Inspection ase incl Inspection 9 _ <br /> Inspection By Date Inspection By. ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1'&Received By-January 31 ❑ July 1 &Received Ry July 31 <br /> BILLfNG REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> RATE DATE REMITTED AMOUNT <br /> FEE 5 <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY 4 <br /> OTHER <br /> OTHER <br /> Received by �v Date Receipt No. Permit.NW Iss ance Dae Mailed Delivered + <br /> A <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -401 E.HAZELTON AVE:,P.Q.Box 2009 ,STOCKTON,CA 95201 <br />