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Applications Will Be Processed When Submitted Properly Completed Be�L! <br /> A toSign The Application. <br /> FOR OFF5PE USE: APPLICATION SAY 1981 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMITCAN <br /> r CAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEAL` IA DISTRICT <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordina cc No. 16&S a the rules and regulations of the San &uVi LocajeHpalth District. <br /> Exact Site Address &C_5—C9_5— City/Town <br /> Owner's Name r�'rs Phone 1 <br /> Address City— <br /> Contractor's <br /> ity Contractor's Name S icense Business Phone__ <br /> Contractor's AddressY Emergency Phone U) <br /> 1 <br /> Is Certificate of Workman's Compensation Ins ante on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN RECONDITION 11 DESTRUCTION❑ ! <br /> WELL CHLORINATION-13 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRM <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank14 ��1 Sewer Lines /( PiY Privy <br /> Sewage Dispos Field Cess; I/Seepage Pitr �- <br /> Property Line` �l rwate Domestic Well / Public Domestic Well <br /> INTENDED USE TYPE OF WELL ` 7-3 � <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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sylaoe S In alled B <br /> PUMP INSTALLATION: Contractor f <br /> Type of Pump - <br /> PUMP REPLACEMENT: ❑ State Work Done -F <br /> PUMP REPAIR: RI- ate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure ILA <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 of the work for which this permit t <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 /> I II f r a u pection prior to grouting and a final inspection. <br /> Signed �---� Title: Date: <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date b O <br /> Additional Comments: <br /> Phase 11 Grout Inspection /feria 111 Final Inspection <br /> Inspection By o Date Inspection By/ Dated 7-j--V_ <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 /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issua ce Dat6 Mailed Delivered <br /> _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />