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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheApplication. } <br /> APPLICATION <br /> FOR OFFICE_U.SE: ., t <br /> —�� — (For Non-Transferable, Revocable,Suspendable) <br /> ;�•�° PUMP&WELL ' <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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. 1B 2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Ar —� ►fi Cit— y/Taw' y <br /> Qwng=ame �'f} ►ifsr f a M �5 c, •''° Phone 7 <br /> - -- <br /> �. City ' G f} <br /> Addre �� 5 <br /> Contractor's Name License# Business Phone <br /> Contractor's Address i Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑_ DEEPEN 11RECONDITION❑_DESTRUCTION❑ _ f _ &J. I <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION PUMP REPAIR 1 <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 <br /> TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION - ❑ GRAVEL PACK Depth of Grout Seal d <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor I"! f S <br /> --Ir 44 <br /> T e Of <br /> PUMP <br /> _ REPLACEMENT: State Work Done U�. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> Thereby certifylhat 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 torwhich this <br /> permit is issued, I shall employ,persons subject to workman's compensation laws of California." <br /> �i <br /> I will II for a Grout Inspection-pri 'r to grouting and a final inspection. ,5 <br /> Signed X Title: Date: <br /> (Draw Plot Plan on on Side) ~ <br /> j <br /> + <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 `• �� <br /> Accepted By <br /> Date <br /> Application p _ <br /> h Additional Comments: <br />` Phase 11 Grout Inspection Phaa III Final Inspection <br /> Inspection By Date Date Inspection By Date <br /> Fee 1s Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> REM4T <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I;. BASE - EXPLANATION DATE DATE REMITTED AMOUNT <br /> - O <br /> FEE <br /> LESS ~ <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> kt <br /> OTHER y <br /> OTHER y u <br /> _ Permit No. <br /> Received by Date Receipt No.. Issuance Date Mailed Delivered <br /> — V _• <br /> sooucaraT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,+ 1601 E.HAZELTON AVE.,P.O.Box 2009 - STOCKTON,CA 95201 <br />