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y._ App 7a tions Will Be Processed When Submitted Properly Completed.Be u <br /> & LI ON - <br /> I FOR OFFICE USE:_ <br /> a.. (For Non-Transferable,Revocable,Suspendable) / PUMP&WELI <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) " <br /> Application isbereby made to the San Joaquin Local'Health District for a permit to construct and/or install the work,herein described.This application <br /> made in compliance with San Joa uin Co l t mance No. 1 62� d the rules a re ulations of the San Joaqu'n L al Health District. <br /> City/Town <br /> 40 <br /> Exact Site Address t <br /> Phone <br /> Owner's Name City <br /> Address '}Business'Phone- <br /> Contractor's Name ' = License`# <br /> 4" Emergency Phone <br /> Contractor's Address " Emergency <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes <br /> o - <br /> TYPE OF WORK'(CHECK W NEW WELL❑ YDEEPEN ❑' 'RECONDITION❑ DESTRUCTIO PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP I <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank' Sewer Lines y <br /> + Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 11DOMESTIC/PRIVATE El DRILLED Dia. of Well Casing <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> 0--IRRIGATION <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> © DISPOSAL: ' Other Information <br /> _ 1:1 OTHER <br /> ❑ GEOPHYSICAL - Surface Seal Installed-By: <br /> PUMP INSTALLATION: Contractor 0 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT '❑ State Work-Done <br /> PUMP REPAIR: ❑ State Work Done <br /> F <br /> DESTRUCTION OF.WELL: Wel! Diameter Approximate Depth <br /> Describe Mate <br /> ti rial and Procedure; <br /> I'hereby certify that 1 have pri epared 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 /> t 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 orsub-contracting signature certifies the following:"I certify that i.n 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 will call for a-Grout Inspection prior to grouting and a final inspection. } G <br /> Title: Date: /(J <br /> Signed X <br /> j (Draw Plot Plan on Reverse Side) <br /> A <br /> FOR DEPARTME T USE ONLY <br /> F <br /> r, f / <br /> i Date / <br /> on Accepted By <br /> al Comments: <br /> pection p Ph a Ill Final Inspection`` <br /> Datef 91 -* <br /> Inspection By s Grout InsDate Inspection By <br /> ` <br /> ❑.July 1 &Received July 37 <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31'- REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> -- - BASE EXPLANATION' - DATE DATE REMITTED AMOUNT <br /> r ,EEE <br /> LESS. t <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER { <br /> OTHER f <br /> �.i <br /> - Issuance Date Mailed - -� Delivered -- <br /> Received by <br /> Date Receipt.-No,` -- Permit No <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.So=2009 STOCKTON,CA 95201 <br />