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Applications Will Be Processed When Submitted Properly Complete. py eAPohe Application. <br /> FOR OFI=iCE USE: APPLICs I ry It / <br /> (For Non-Transferable, _ a spWndable) PUMP&WELL �/ r <br /> ENVIRONMENTAL LT � RT%�q$� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstruc r'n al ,vkherein described.This application is <br /> made in compliance with a JvaquiCQunty Ordinance N�1 and the rules .re pji on f 1� ►TJ4a ui cal Health District. <br /> Exact Site Address H �/jt'7'- <br /> r� City/Town P <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name y� License#f 3 7.7 Business Phone J <br /> r%��� <br /> Contractor's Address r Emergency Phone i <br /> Is Certificate Of Workman's Compensation Insurance on File With SJLHD? Yes L.— No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ W <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 <br /> Property Line Private Domestic Well Public Domestic Well <br /> NTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ Dy MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ D MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ I RIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ ATHODIC PROTECTION ❑ ROTARY Type of Grout _ <br /> ISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 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." <br /> Contractor's Kirin - b-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is is e ! hall emploors ns subject to workman's compen n laws of California." <br /> 1 wil all ro spect n priorJo grouting and a final Inspecti <br /> !K. <br /> 0 0-11ry <br /> Signed X Title: Date: T / <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE# <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection h e III Fina spection d <br /> Inspection By Date Inspection B ate <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 Q July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $. AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Q <br /> Received by Date Receipt No. Permit No ssuanc Dat6 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />