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A: Application J1dog W_P4k&ubmlt1ed Properly Completed. Be Sure To Sign The Application. <br /> 0;47i0A_Ok, ICE USE: APPLICATION <br /> SAN .J �]QUl (_FFor Non-Transferable, Revocable,Suspendable) 7 <br /> HEALTH t'UC. PUMA WELL <br /> D15TR6ONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ; <br /> f Application is hereby madeto the San Joaquin Local Health District fora permit toconstruct and/or install the work herein described. This application is <br /> made in compliance with n aquin ounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site. City/fawn <br /> Owner's Name Phone <br />€ Address Gity <br /> Contractor's Name License# Business Phone_ <br /> Contractor's Address Emergency Phone \J <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes NoX_ �! <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ { <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ t 57 <br /> DISTANCE TO NEAREST: - -Septic Tank . Sever Pit-Privy— <br /> Sewage Disposal Field Cesspool/See page Pit Other —7'/4-- <br /> Property Line � 0 <br /> p y1� Private Domestic Well _�Q Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑- INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE El 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 ❑ OTHEROther InformationI <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H p <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP,REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth t <br /> Describe Material and Procedure <br /> I•hereby ce-rtify hat 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 Safi 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 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." h <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, 1 shall employ persons subject to workman's compensation laws of California."' <br /> .I wit call for a Grout Inspec ion priorto grouting and a final inspection. <br /> Signe Title: L9C Date. _U °/i' �� Y <br /> (Draw Plot Pian on Reverse Side) -� <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Dat <br /> Additional Comments: t <br /> Phase 11 Grout Inspection P pection <br /> Inspection ByDate _ Inspection By Date � 7 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JWy 1 &Received By July 31 <br /> RASE EXPLANATION BILLINGREMITTANCE -4 $ REMIT <br /> DATE DATE " REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE $45.00 <br /> LESS _ <br /> PRORATION r <br /> PLUS <br /> PENALTY { <br /> OTHER <br /> OTHER <br /> 3�3 <br /> Received by Date Receipt No ermit No., ssuanc Dat Mailed Delivered <br /> } ,APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />