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Applications Will Be Processed When Submitted Properly Completedo3eIre gn The Application.APPy� <br /> FOR OFFICE USE: nsfera eI I'[ �� <br /> • , �. <br /> (Far Non-Transfera� e1� s n able) <br /> PUMP&WELL <br /> ENVIRONMEN EALTH �ETIMT9 <br /> (COMPLETE IN TRIPLICATE) WAT QUALI U IM <br /> Application is hereby madeto the San Joaquin Local Health District fora permit to construct t��llruork herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rd ``&,nd�� M-yllRkelan Juin Local Health District. <br /> Exact Site Address <br /> /pee L� ity/Town <br /> Owner's Name �l "'* 11 f Phone P <br /> Address VV City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address -0- EmergencyPhone <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 ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field' Cesspool/Seepage Pit Other x <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE 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 W <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal t <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump A.- 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 /> i <br /> I hereby certify that 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 /> Home owner 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." Y <br /> i Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> e_ <br /> Signed X °" /_./L�� JF PFJ Title: Date: <br /> Ir (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE q <br /> Application Accepted By Q Date <br /> r <br /> Additional Comments: <br /> Phase II Grout Inspection P III Fin nspeclion� �D <br /> Inspection By Date J Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 1rPFR SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 6 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> l�� s� <br /> i LESS <br /> PRORATION # <br /> PLUS 1 <br /> ` PENALTY <br /> 1 OTHER + <br /> OTHER <br /> Received by Date Receipt No. Permit No. tssua ce❑ to Mailed Delivered <br /> E <br /> STOCKTON,CA 95201 <br /> .APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 <br />