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Applications Will Be Processed When Submitted Properly Completed:Be Sure To Sign The Application. <br /> }AOR OFFICE US€: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) I <br /> PUMP&WELL <br /> ENVIRONMENTAL-(HEALTH PERMIT j <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY J <br /> Applic"ationishereby made tothe San Joaquin Local Health District fora permit toconstruct and./or install thework herein described.This application is Dq <br /> made in compliance with San Joaquin County rdina a No. 1862 and th r es and regulations of the San Joaquin Local Health District. <br /> ail: <br /> Exact Site Address _ City/Town reog # <br /> Owner,s Name _ Phone r <br /> Address 7 t City + <br /> Contractor's Name LicensrJiVBusiness Phone l-z <br /> ContralIctor's Address mergency Phone 7-4( 17— k <br /> Is Certlificate of Workman's Compensation Insurance on File With SJLHD? Yes L-- No <br /> TYPE'.OF WORK (CHECK): . NEW WELL®---bEEPEN ❑ RECONDITION❑ DESTRUCTION❑ d <br /> WELLII CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> i <br /> REPL4CEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank /Y� ,e Sewer Lines Pit Privy <br /> j Sewage Disposal Field_ Cesspool/Seepage Pit X44- yOther <br /> PropertyLne $Private domestic Well�blic Domestic Well <br /> INTENDED USE TYPE OF WELL 1 et✓ <br /> ❑ INOUSTRIAL ❑ CABLE TOOL ©ia'. of Well Excavation <br /> &-DeM—ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 4�,- S <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CAi�THODIC PROTECTION 9'FCARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal lnstalledjBy: c = <br /> PUMP i INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: ❑ State Work Done n <br /> PUMP&EPAIR: ❑ State Work Done S rt <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth F <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County. _ <br /> i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ! <br /> i <br /> I <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certity that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I will c for a Grout Inspection prior to grouti g nd a final inspection. <br /> ,I$igned X c�-�►�'�- Ti#le: lam[v��_.�.,� Date: <br /> l <br /> (Draw Plot Plan on Reverse Side) <br /> III w j OR D ARTMENT USE ONLY // j <br /> :PHASE ! oz /, / <br /> IljApplicationtAccepted By Date/ /%f/�.. <br /> ) <br /> (Additional Comrcte to s: ^ t <br /> > I , Phase II-G out Inspe _on 3 P II Final spection <br /> „ I Inspection By �' ,` r .to Inspection B Date <br /> ■ <br /> Fee,Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 . r <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> + � AMOUNT <br /> ;FEE <br /> LESS <br /> LPRORATION <br /> PLUS <br /> PENALTY - ,� <br /> # OTHER r - <br /> ,� 4 <br /> OTHER <br /> c 4 Rece fed try 'Date Receipt No- Permit'No, sr_, nce Date Mailed Delivered <br /> APPLICANT=RETURN ALLCOPIESTO,;.t ENVIRONMENTAL HEALTH PERMIT/SERYICES"y 1601 E.HAZELTON AVE.,P.O.Box2009STOCKTON;CA 95201 <br />