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Applicatfohi'*Y '!BW"rOGQsssed hd�Subirnitted Properly Completed. Be Sure To Sign TheApplication. <br /> FOR OFFICE USE: t�[ �AP�PLICATI4N <br /> r 1 ! _ (For-N.on-Trac 4able, Revocable, Suspendable) PUMP&WELL <br /> C' 1" 1' <br /> HEALTH PERMIT <br /> SAI'] J O N ) <br /> (COMPLETE IN TRIPLICATE ±�1�t',! LOCAL WATER QUALITY <br /> Application is hereby made tothe San 10 niLocal Healthl-D�tYlctfor apermit toconstruct and/or install the work herein described.This application is <br /> f }3 L 11,03,.. <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 6 City/Town <br /> Owner's Name u y Phone <br /> Address 6 +5° City r_ <br /> Contractor's Name License 1 Business Phone <br /> Contractor's Address p�� y� e"j � _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK(CHECK):/NEW WELL❑ DEEPEN 11 RECONJTION❑ DESTRUCTION D I <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR V1 <br /> REPLACEMENT❑ �I <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 /> INTENDED USE TYPE OF WELL M1 <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation F <br /> bd 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 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 /> 1 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call fora Grout Inspection prior to grouting and a final inspection. <br /> Signed X -i" r Title: Date: to 11- <br /> C/ <br /> (Draw Plot Plan on Reverse Si e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Acceptedw- <br /> Additional Comments: <br /> Phase 11 Grout inspection hase III Final spection <br /> Inspection By-n\Ch, Date Inspection By L Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 4 &Recei a By January 31 ❑ July 1 &ReceNed 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 /> S a Vv <br /> Received by Date Receipt No. Permit No. I uance ate Mailed Delivered <br /> .APPLICANT—RETURN ALL COPIES TD: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bor 200 STOCKTON,CA 95201 <br />