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T� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ``► R'oFICE USE: APPLICATION <br /> rsr... <br /> (For Non-Transferable, Revocable,Suspendable) BUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) [Sop , G c.a,Pa WATER QUALITY 025— top--0-3 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> made in compliance ith S n Joaquinou ty Ordinance No. 1662 and the rules and regulations of the San Joaquin Local ealth District. � <br /> Exact Site Address /+ City/Town <br /> h <br /> Owner's Name Phone ! <br /> Address City LL�� <br /> Contractor's Name C C License# 3 55 Business Phone T <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? 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 fr <br /> I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavatwz7:1 <br /> r <br /> 9d DOMESTIC/PRIVATE 13 DRILLED Dia. of'Well Casing <br /> 13DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing 's <br /> El IRRIGATION 11 GRAVEL PACK Depth of Grout Seal � <br /> ❑ CATHODIC PROTECTION $2 ROTARY Type of Grout 71 <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed�Ca, Pull 6d <br /> 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 DiameterApproximate 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. !i <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." <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 Gropt Inspection prior to grouting and a final inspectio <br /> Signed Xnt- Title: Dale: <br /> i (Dra Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> r PHASE <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By 4' -'3 Date 2- <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 �RETTANCE $ AMOUNT DUE:' CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> L OTHER ' <br /> OTHER <br /> '�12to Z ,,,� f <br /> r <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> L APPLICANT­RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA as2ar - <br /> t <br /> `. <br />