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icaiion�lAtiPII�9� VssedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> r FOR,13FFICE-USE: A �� !! r � APPLICATION <br /> r <br /> �rll�on-Transferable, Revocable, Suspendable} <br /> SOA �,S ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE-IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San 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 Ordinance No. 1862nd the rules and regul i gny of the San Joaquin Logy I H alth Distict. <br /> Exact Site Address h. e _(fifty/Town <br /> Owner's Name _ Phone <br /> Address City <br /> Contractor's Name t� �' License # Business Phone <br /> Contractor's Address Emergency Phone1S-Oa / <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes y No f <br /> TYPE OF WORK (CHECK): NEW WELL UP' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> f WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Line F - Pit Privy <br /> Sewage Disposal Field_ /Q� f Cesspool/Seepage-Pit Other <br /> Property Line T --Private Domestic Well Public Domestic Well \ <br /> INTENDED USE TYPE OF WELL N <br /> ❑ INDUSTRIAL ❑ r <br /> CABLE TOOL - Dia, of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED n <br /> � Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ D�VEN Gauge of Casing <br /> ❑ IRRIGATION ,M�, (GG AVEL PACK Depth of Gyout Seal <br /> C1 <br /> CATHODIC PROTECTION L OTARY Type of Grout <br /> C ❑ DISPOSAL O'OTHER Other Information — b <br /> ❑ GEOPHYSICAL H Surface Seal Installed By. <br /> PUMP INSTALLATION: Contractor <br /> FType of Pump H.P. <br /> r PUMP REPLACEMENT: 'is' El State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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 /> I will call for a Grout I pection prior to grouting and a_fin I inspection. - <br /> .' <br /> Signed:X -.Date: <br /> XFC <br /> =(Draw Plot Plan on Revere Side) �' <br /> } `*4 F R DEPAR MENT USE ONLY <br /> PHASE I •£ „� <br /> Application Accepted By1) ? <br /> e Date ' <br /> Additional Comments: '�'^' - <br /> _ Pha Grout Inspecti14 Phase Final Inspection <br /> Inspection By Date 2,3f 80 Inspection By Date 3- <br /> AFIr <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER --'r❑January'l-8 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ -� REMIT <br /> BASE- -EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> LESS r <br /> PRORATION <br /> t PLUS <br /> PENALTY - <br /> OTHER - <br /> _ <br />` OTHER <br /> Received by Datf € Receipt No. Permit No. Issuance Date Mailed Delivered - !+ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.D.Box 2009- STOCKTON,CA 95201 <br />