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T Applications Will Be-Processed When Submitted Properly Completed. Be Sure To Sign The Application. . <br /> P'JPrOFFICE USE: i' APPLICATION <br /> (For Non-Transferable, Ravocable,`Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Ij WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) V '13 r"f <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Jo quin Local Health District. <br /> ,$ 'l4 City/Town <br /> Exact Site Address i <br /> 6 <br /> 111 <br /> Owner's Name Phone� M <br /> Address s �/ i! �X�n� —� �. .� City <br /> Contractor's Name License# Business Phone l <br /> Contractor's Address • d,. kZ 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 13WELL ABANDONMENT 13OTHER 13PUMP INSTALLATION PUMP REPAlR❑ ' <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 <br /> ' ❑�.f�DUSTRIAL {!! " " -Ei CABLE TOOL Dia:of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED " Dia. of Well Casing <br /> ��``DOMESTIC/PUBLIC ❑ DRIVEN' ' Gauge of Casing <br /> ❑ IRRIGATION jj ❑-GRAVEL PACK Depth of Grout Sdal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> El DISPOSAL II ❑ OTHER �- x Other Informatiori <br /> ❑ GEOPHYSICAL II � Surface Seal Instilled By: <br /> PUMP INSTALLATION: <br /> u G7 ' � •� <br /> H.P. <br /> , T'yp�{�f1Purfip L'•, -P. —Z <br /> PUMP REPLACEMENT: u <br /> ❑ State <br /> PUMP REPAIR: 01 Sfka Work Don <br /> DESTRUCTION OF WELL: j Well D1a Appr ximate Depth <br /> ''ffrr <br /> Describe Material d Procedure <br /> I herebycertifythat I have re Ired this �Io <br /> a _ atlo and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws;_and rules and regula onstof,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 for which this <br /> permit is issued, I shalI'l employ persons subject to workman's compensation laws oI f California <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: + -_. . Date: <br /> 4 y— <br /> .� (Draw Plot Plan an Reverse 5i¢ ) <br /> - <br /> ij FOR DEPARTMENT USE ONLY <br /> PHASE I »JA_ ��^ _ <br /> LIOC�I,. k Date�� <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection hase III Final Inspection <br /> Inspection By Date Inspection By 7 -a+ Date -o- <br /> Fee Is Due: ❑ ANNUALLY "❑ PER UNIT ❑ PER SITE `❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received 8y July 31 <br /> REMIT <br /> BASE - EXP.LANAT40N BILLING" = REMITTANCE $ -AMOUNT DUE CHECKED <br /> " ,DATEDATE REMITTED AMOUNT <br /> ,1 <br /> FEE - <br /> ys <br /> LESS <br /> PRORATION <br /> i <br /> PLUS 1 - <br /> PENALTY <br /> OTHER .G <br /> OTHER <br /> 131 <br /> Received by Date --Receipt No.`• Permit No.- Issuanc Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />