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Applications Will Be Processed When Submitted Properly Completed. tie 51T <br /> Ia bignineAppucaliun. LLJJ <br /> FOR OFFICE USE: APPLICATION R 18 1981 <br /> - . (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN 1-n(-AL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEA" -3 H DISTR'G'T <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County 0 di a No.186 and h_ rules and r ul tions of the Sa Joaguit� Local Health District. <br /> Exact Site Address l t" City/Town _�r',� 1 <br /> Owner's Name Phone C if C S <br /> a <br /> Address ~' #� rr City = _ <br /> 1 i C.� Business Phone 7 t <br /> Contractor's Name ri � � � License# <br /> Contractor's AdYA � Emergency`- g y Phone �— <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No <br /> TYPE OF WORK (CHECK): NEW WELL M--' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ „� t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR�� 1 <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 3 Pit Privy �L}.�—�. <br /> Sewage Disposal Field Cesspool/Seepage Pit Other w <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation l <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing lxc <br /> 2'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor R <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done s <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 thework 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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection pgWr to grouting and a final inspection. <br /> Signed XTitle: Date��" Z , � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> n <br /> PHASE ! <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phas# III Final Inspection / <br /> Inspection Bye,�t Date _ Inspection Bte <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> f 6 z Ls <br /> Received by Date - Receipt No.. Permit No Issuan a Date Mailed Delivered <br /> }' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />