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- Ap fibs Will Be Processed WFz�ubmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: ApR 2 a 19$0 APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> :.SAN JOAQUIN �ONMENTAL HEALTH PERMIT � <br /> ptSTR11 <br /> (COMPLETE IN TRIPLICATE) HEALTH s WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Hl?filth District fora permit to construct and/or install thework.herein described.This application is <br /> made in compliance with San Jo/a`quin Coun Ordinarsce No. 1862 and theses and regulations of the San Joa in Local Health District, <br /> Exact Site Address +� �f 7m e.� �1 City/Town <br /> Owner's Nam Phone <br /> Address City r <br /> j , 9b�s W <br /> Contractor's Name p License# !or�J3 Business Phone6Z-y <br /> Contractor's Address Emergency Phone <br /> i <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 i Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> i Property Line Private Domestic Well "'Public Domestic Well - <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> J DOMESTIC/PRIVATE ❑ 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 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I Surface Seal Installed By: X41 <br /> PUMP INSTALLATION: Contractor J <br /> r <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Donet <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth Qi <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. <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 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. <br /> Signed X Title: :1'17/,L,i 6L,'!4AZ- Date: - O <br /> (Draw Plot Plan on Reverse Side) Lf _. <br /> FOR EPAR MENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout InspectionPhase II Final insp lion <br /> Inspection By Date Inspection By ate <br /> q-1 gy <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT P <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ef DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION <br /> t <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> �r 3aa <br /> Received by Date Receipt No. - Permit No, is uance D to Mailed Delivered fi <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br /> ��S <br />