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Applf46Fh 1011 BIfti�taeessee`d'fflrhen Submitted Properly Completed. Be Sure To Sign The Application. tip, <br /> FO OFFICE USE: .•7+���� APPLICATION <br /> SA <br /> N JQA�7UtN M7..�FLor Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> EALTH DISTRICCT ENVIRONMENTAL HEALTH PERMIT <br /> t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or installthework herein described.This application is <br /> made in compliance with S a uin Count Ordinance No. 1862 d the rules and regulations of the Sa ,o,1aa.,quin L c 1II Health District. <br /> kExact Site Address City/ToA.. T f <br /> Owner's Name _ Phone <br /> 6"- <br /> Address W City q Q <br /> Contractor's Name v j License# �6 Business Phone , <br /> E Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ � = <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 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 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> C ❑ GEOPHYSICAL Surface Seal Installed By:. <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump H.P. <br /> Ik PUMP REPLACEMENT: ❑ State Work Done <br /> I PUMP REPAIR: 00 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> ' I Describe Material and Procedure <br /> I <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w' all for a out Inspe tion priaLjo grouting and a final inspeemn. <br /> I Signed X Title: / �7 —� �h/ � Date: ~� <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> r, Phase If Grout Inspection P ase 111 F al Inspection <br /> Inspection By Date Inspection Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> 4 DATE DATE REMITTED AMOUNT <br /> i <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 4 <br /> OTHER <br /> { OTHER <br /> f �b <br /> Received by Date Receipt No. Permit No ssuance Date Mailed Delivered y <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201' <br /> ', <br />