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F, f Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMA&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto constructand/or install the work herein described.This application is f <br /> made in compliance with San Joaquin Count Ordinance No. 1862 an th rules and regulations of the San Joaquincal Health District. <br /> r q Cj y ; City/Town <br /> Exact Site Address <br /> Owner's Name '°� oN Phone '/ <br /> Address q <br /> City— <br /> Contractor's Name License#56W9Business PhoneG <br /> Contractor's Address 11 L Emergency Phone - 1 T <br /> Is Certificate of Workman's Compensation Insurance on File Wit SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONDESTRUCTION[--] <br /> WELL CHLORINATION ElWELL ABANDONMENT ElOTHER 13PUMP INSTALLATION ❑ PUMPRE <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL - <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Weil Excavation <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <br /> i s <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 1}- <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information i <br /> C1 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> i" PUMP REPAIR: State Work Done <br /> ise <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 4 <br /> Describe Material and Procedure <br /> a. <br /> f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County CA <br /> ffff 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." b <br /> 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 /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> 1 FOR DEPARTMENT USE ONLY <br /> PHASE [ <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection h se ill FM41ction <br /> Inspection By Date Inspection 8y ate 3-11- <br /> Fee Is Due: ❑ ANNUALLY _ ❑ PER UNIT - - ❑-PER SITE- ❑ EACH ❑..January 1.&.Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 0 <br /> FEE Q(J SYS C}U <br /> l LESS <br /> C PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ered <br /> ' Received by Date Receipt No, Permit No. Issuance Date Mailed De iv'To <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P"O.Box 2009. STOCKTON,CA 9520 <br />