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ti Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 'T+ R`OF7J ICE USE: 9 APPLICATION <br /> �. (For Non-Transferable, Revocable, Suspendabie) <br /> f PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT , <br /> (COMPLETE IN TRIPLICATE) #ALITY i <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work,herein described.This application is <br /> P. <br /> made in compliance ith San Joaquin County OrdinInce No. 1 62 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address � S cv� . ' fJ� It /Town <br /> Owner's Name Phone <br /> Address ?fir City r <br /> Contractor's Name G Icense# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL&0'0�DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHERY PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer�s F Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Ottier ' <br /> Property Line Private Domestic Well Public Domestic Well s <br /> INTENDED USE r Y E OF WELL <br /> ❑, IN STRIAL !' ABLE TOOL Dia. of WeII Excavation � r <br /> DOMESTIC/PRIVATE El DRILLED Dia. of Well Casing Ig 4 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK _ Depth of Grout Seal \ <br /> 11 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 13 DISPOSAL El OTHER Other Information <br /> ❑ GEOPHYSICAL *. Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractors <br /> it .Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ <br /> PUMP REPAIR: I' ❑ State Work Done <br /> - �1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> jl 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 /> 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 forwhich this i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> rillol f r a Gr ut Ins on p ionto grouting and a final inspections <br /> Signed X r Title: 411C Date: "�/ 'Air <br /> it (Draw Plot Plan on Reverse Side) <br /> i ' <br /> i <br /> + !� FOR DEPARTMENT USE ONLY <br /> PHASE I I! <br /> Application Accepted By '" �`�-'d, Date ~ rR~ <br /> Additiq,rab Comments: <br /> ,�, Ph a Grout nspection `,,'_P e Final I ection <br /> Inspection By 4� Date S Inspection Byvu at <br /> Fee Is Due: ❑ ANNUALLY ;❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> WASE It EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ( � AMOUNT <br /> FEE <br /> LESS <br /> PRORATION 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br />- OTHER li ..... . <br /> Received by -Date � Receipt No. Permit No. Issu nce 15ate Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601'E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 95201 '� <br />