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A ations Will13�e Prof9 d When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: DEL l� 10 APPLICATION <br /> �( nll� n-Transferable, Revocable,Suspendable) ' PUMP& ELL <br /> SAN �.:. <br /> HEEALTH DISTMIA11RONMENTAL HEALTH PERK <br /> (COMPLETE IN TRIPLICATE)- WATER QUALITYf / <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work,herein d cribed.This application is <br /> made in compliance with San Joaquin County.Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> 6171 E. Hiw ..,. 2 FCity/Town° •✓ <br /> Exact Site Address <br /> Owner's Name ' '="'T r' ` Phone 7 '9 —.6397 � n <br /> Address -:01 t1 City ' st-c3nktAn �1 <br /> Contractor's Name = License# 7F7F,Q6, Business Phone + <br /> Contractor's Address 474 C u� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RrCONDITION❑ DESTRUCTION,❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 1 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 /> NDUSTRIAL ❑ CABLE POOL Dia. of Well Excavation <br /> ❑ OMESTIC/PRIVATE 1-1DRILLED 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 . +. ,. -,-+K ._- ...-Surface Seal Installed By:: <br /> PUMP INSTALLATION: Contractor <br /> Type .Pump �!' H.P. <br /> PUMP REPLACEMENT: EState Work Don f <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 9 <br /> 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wit all forra Grout Inspection prior to grouting and a final inspection. -j <br /> r TitleC:� - ��t -p� : <br /> Signed X : Date. <br /> ' <br /> (Draw Plot Plan on Reverse Side) <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ' Phase III F' al Inspection <br /> rR_ <br /> Inspection By Date Inspection By Date _ <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 DUE CHECKED <br /> DATE DATE EMITTED AMOUNT <br /> FEE ¢ <br /> LESS <br /> PRORATION <br /> PLUS ' <br /> PENALTY <br /> OTHER <br /> I - <br /> OTHER F3 <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.Box 2009 STOCKTON,CA 95201 <br />