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Applications Will Be Processed When Submitted Properly Cor pmt5S aApplication. <br /> FOAOFFICE tfSE: APPLIC�► 1 vi <br /> (For Non-Transferable, RevocTb I;pendable) PUMP&WELL <br /> ENVIRONMENTAL �ILTH�n�R�IT 19$O �. <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit too tXtictpnd}(0Yt,L�VL9II1herein described.This application is <br /> made in compliance with San Joaquin County dina ce No. 1862 and the ruiesd;ragarJatiti�lsSI aquin Local Health District. <br /> City/Town <br /> Exact Site Address_ e ¢ <br /> Owner's Name , Phone 3 697 <br /> Address e) &., r City &C-0 <br /> Contractor's Name License V(42 3�� Business Phone .? (k <br /> Contractor's Address l d) Emergency Phone C <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 t <br /> REPLACEMENTO-' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 0(j <br /> Sewage Disposal Field Cesspool/Seepage Pit Other f <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 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL � Su ace Seal Installed y: <br /> PUMP INSTALLATION: Contractor Q`S <br /> Type of Pump 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 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 ;al�Iora-G�rou)Any�pection-prior io-- uting-and'a final inspection. . <br /> Signed X Title: � Date: <br /> (Draw PI n on Revers Side) , <br /> FOR DEPARTMENT USE ONLY <br /> PHASE -`. <br /> Application Accepted By_�--.�iJ# Date � d <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase Ili Final Inspection <br /> Inspection By Date Inspection By Date '��� <br /> I <br /> Fee Is Due: ❑ ANNu ALLY PER UNIT ElPER SITE ❑ EACH E3January 1 &Received By January 31 ElJuly I &Received By July 31 <br />' REMIT <br /> BASE EXPLANAT$ON BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> G � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> O�w ,o4 -71 q/ko <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201'- <br />