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App' �orf�W I Be Proicessge hebmiiied Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE APPLICATION ` <br /> or N ransferable, Revocable, Suspendable) PUMP&WELL t/ <br /> Sita 3 � NMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> l nM <br /> (COMPLETE IN TRIPLICATE) H - ' <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 Ordi ante 1$62 and the r Iles and regulations of the San Joaquin ocal Health District. <br /> Exact Site Address City/Town <br /> r <br /> :� 9 t <br /> Owner's Name Phone <br /> City . <br /> Address <br /> ; Lice rise iness Pffo e <br /> Contractor's Name <br /> Contractor's Address - �G /L� _ - <br /> t. °P' Emergency Phone <br /> 1 <br /> Is Certificate of Workman's C mpensation Insurance on File With SJLHD? Yes No <br /> No - <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDElITION DESTRUCTION❑ k <br /> WELL CHLORINATION ❑ WELL ABANDONMENT TO. OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL { '� <br /> 1�1,�INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> L�3'DOME57iC/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 E] OTHER Other Information �- <br /> Surface Seal, Instalied By:' i <br /> ❑ GEOPHYSICAL a <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P <br /> PUMP REPLACEMENT- ❑ State Work Done <br /> PUMP REPAIR: tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <br /> I hereby certify that I have prepared this application and that the work will be-done in acc&dance with San JoIn <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 certifythat in the performance of the work for whiis issued, I shall not employ any person in such manner as to become subject to workman's compensation laws Contractor's hiring or sub-contracting signature certifies the following'."1 certify that in the performance of the workpermit is issued, I sha11 employ persons s ctto workman's compensation laws of California." I <br /> I w for rout inspe lo o rout' and a al inspection. <br /> Signed X Title: - Date: <br /> (Draw of an on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I y I' (h a Date +� ` <br /> Application Accepted By <br /> t Additional Comments: <br /> Phase it Grout Inspection se�Finalspection II \ <br /> Inspection By —Date Inspection By Date + <br /> Fee Is Due: ❑ "ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DAVE DATE REMITTED AMOUNT <br /> JAR <br /> FEE <br /> k LESS <br /> PRORATION <br /> PLUS <br /> PENALTY' <br /> OTHER <br /> OTHER <br /> � Issua Date Mailed Delivered <br /> Received by- Date Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.8o■2009 STOCKTON,CA 95201 <br />