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Ap I Ions Will Be r c Whe""ubmitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE USE' ulAY � � APPLICATION U <br /> i 111 (For�t�rl-Transferable, Revocable, Suspendable) PUMP&WELL <br /> SAN JDA'-v MHtONMENTAL HEALTH PERMIT ' <br /> \ HEALTH Dl��`' WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) 6'. <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 with San Joaquin CiZ Orin nce N . 1862 a d e rules and regulations of the San aq in Health District. <br /> City/Town, <br /> Exact Site Address (+� _ <br /> Phone <br /> Owner's Name <br /> Address ` City <br />` License#2X(,[I _ - Business Phone':, <br /> Contractor's Name r <br /> Contractor's Address r 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❑ DESTRUCTIONS <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> I 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 O� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 01 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑.DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> fIS dialGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 13CATHODIC PR TECTION 11ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br />' ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done lr <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> y Describe Material and Procedure ' <br /> F 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. <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.";; <br /> I wi1F all f. r a G u Inspection prior to grouting and a final ins tion. <br /> i F� <br /> Signed X Title: �� Date: ' <br /> (Draw Plot Plan on Reverse Side) 'I <br /> t O. EP ,T.MENT E ONLY <br /> PHASE G <br /> Application Accepted By _ Date <br /> Additional Comments: , <br /> y Phase 11 Grout Inspection -,.. Phase III Final Inspection e <br /> i - `( Dat <br /> Inspection By Date ` Inspection By <br /> I ., <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 /> ti DATE DATE REMITTED AMOUNT <br /> t <br /> n <br /> FEE <br /> 1 <br /> LESS <br /> S. PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER II <br /> Received by- Dat Receipt No. `, Permit No. Issuan a Date;: Mailed Delivered „ - <br /> r APPLICANT—RETURN ALL-Coga TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ,ate: <br />