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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> h <br /> (For Non-Transferable, Revocable,Suspendable) <br /> N IRON*MENTAL HEALTH PERMIT PUMA&WELL <br /> (COMPLETE IN TRIPLICATE) � V .5� I WATER QUALITY <br /> Application is hereby made to the San Joaquin LocalHealthDistrict for apermit toconstruct and/or install the work herein described.This application is <br /> made in compliance withSanJoaquin County Ordin nce No.1862 and the rules and regulations of the San Joaquin Lo I Health District. <br /> Exact Site Address i�l .r �..r f -� = City/Town ,a4,�1 eL44 Iy — <br /> t <br /> Owner's Name Phone . <br /> Address City = Cgl <br /> Contractor's Name LI nse#� �.. Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman s Compensation Insurance on File With SJLHD? Yes No 4 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ Ir" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ tet— <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 r i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge Of Casing F <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Q ROTARY Type of Grout (7444 # <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor n. �I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure + <br /> s <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <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 i <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." 1 <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." j <br /> -1 will)ccalllfoor a Grout inspection prior to grouting and a final inspection. // C� <br /> Signed X CTitle: Date: L6 � <br /> (Draw Plot Plan on Reverse Side) <br /> x: FOR DEPARTMENT USE ONLY ? <br /> PHASE I } <br /> Application Accepted By — Date <br /> Additional Comments: <br /> P ase N Grout Inspection Phase III Final Inspection ' <br /> Inspection By� Date Inspection By Date <br /> 11 <br /> Fee Is Due: ❑ ,ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1-&Received By January 31 ❑ July 1 &deceived By July 31 <br /> REMIT <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> k DATE DATE REMITTED AMOUNT <br /> FEE 3 _ 43 I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i Received by Date Receipt No, Permit No. Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 <br />