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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> 1 ?ds E 6i4,�E�IVIRONMENUL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) I p-U�1 � Y�-'►U IeY Ye IV*uY r <br /> Application is hereby made toth an Joaquin Local Health lsrlctforapermittoconstructand/oriristalltheworkhereindescnbed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulation's of the San Joaquin Local Health District. <br /> Exact Site Address '111 <br /> Owner's Name "'. Phone- <br /> Address o City- ' <br /> Contractor's Namer* " License# Business Phonel l$ <br /> Contractor's Address Emergency Phone t Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK)` NEW WELL-T DEEPEN ❑- "'RECONDITION❑ - DESTRUCTION-0 - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ ' <br /> DISTANCE TO NEAREST: Septic Tank X00 Sewer Lines Pit Privy ti <br /> Sewage Disposal Field 100P Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well !N� <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavationm <br /> -DOMESTIC/PRIVATE ❑ DRILLED Dia,.of Well-Casing <br /> 0 DOMESTIC/PUBLIC ❑ DRIVEN Gauge'of Casing <br /> ❑ IRRIGATION ® GRAVEL PACK Depth of Grout Seal 1=7'11 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout n <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> F <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />' PUMP REPLACEMENT: ❑ State Work Done i <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe-Material and Procedure <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 /> Homeowner or licensed agent's sigriature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shallnot employ any person in such manner as to become subject to workman's compensation laws of California." O <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 /> �1\will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed Title: t� rh_— --- _. Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY4 <br /> PHASEI <br /> Application Accepted By - -- Date <br /> Additional Comments: / <br /> Phase rout Inspection Z f _ P III Final Inspection J T E7 <br /> : Inspection By atey -. inspection By � Date <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> t <br /> FEE + . �.� _. 1 <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY # <br /> OTHER <br /> OTHER <br /> Received by Date. Receipt No. Permit No. "Issuance Date- Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM1T15ERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />