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AppJft Will.Be Processed Whe bmitled Properly Completed. Be SureToSignTheApplication. i <br /> FOR OFFICE USE: � � I�� APPLICATION <br /> 3E P. <br /> r ONon-Transferable, Revocable, Suspendable) RUMP&WELL <br /> 10Ak-) j r E NMENTAL HEALTH PERMIT <br /> SAID _ 51 .=,V � <br /> (COMPLETE 1N TRIPLICATE) HEALTH ❑iSTUCiT WATER QUALITY <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County'Oldinance No. 1862 and the r e and regulations of the San Joaquin `Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address City _ <br /> Contractor's Name �+ `� `¢ License� �.ABusiness Phone'7v, <br /> Contractor's Addresy --,OS4 614, Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes .CAS No <br /> TYPE OF WORK (CHECK): NEW WELL 1"— DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ 4 <br /> DISTANCE TO NEAREST: Septic Tank C� Sewer Lines ��� Pit Privy ; <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line 140 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 13INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation d <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _ J <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - <br /> 1 <br /> ❑ IRRIGATION ❑'GRAVEL PACK Depth of Grout Seal <br /> .❑ CATHODIC PROTECTION &-ROTARY Type of Grouts , <br /> © DISPOSAL ❑ OTHER Other Information <br /> © GEOPHYSICAL Surface Seal lnstalied By: 1 <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 /> 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 for which 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 /> A —Title: 1 Date: <br /> Signed X �w s <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I { <br /> Application Accepted By Date <br /> t <br /> Additional Comments: <br /> ase I Final inspection ` ✓�'! <br /> Phase II Grout Inspection <br /> Inspection By .. <br /> Date inspection B ate <br /> Fee Is Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January July 1 eceived By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED } <br /> DATE DATE REMITTED AMOUNT 1 <br /> FEE ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> s <br /> OTHER <br /> f OTHER i <br /> I, Received by ate Receipt No Permit No IssbancelDate Ma�_� Delivered <br /> rf APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,-P.O.-9o:2009 STOCKTON,CA 95201 <br />