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' Applications Will Be Processed When Submitted Properly Completed. Bn S7 T n The Application. <br /> FOR O,Ff_IcE USE:_ APPLICA �g g <br /> (For Non-Transferabf opda le <br /> ENVIRONMENT' EALTH PERM <br /> C n PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATE ALIT11i 7 i"�U <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andgsIE0 rkhereindescribed.Thisapplicationisi I <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rulgp� �� n Joaquin Exact Site Address 6S 6� Local Health District. i <br /> Q <br /> AlyT�own <br /> Owner's Namef Z&- Phone <br /> Address City. <br /> ff <br /> Contractor's Name License # Business Phone 1 <br /> Contractor's Address Emergency Phoneme f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ' No <br /> TYPE OF WORK (CHECK):r NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 6 <br /> WELL CHLORINATION'❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRLR" <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 /> 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 i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: dI <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 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 /> Signed X 0 Cl Citle: <br /> -111 Date: 5-` go <br /> - <br /> (Draw Plot Plan on Reverse Side) <br /> FO EPART ENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phf a Grout Inspection _ 11 Final Inspection <br /> Inspection By Date Inspection By _ Date <br /> 4�& <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT a PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> DATE HATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE vs— <br /> LESS �S <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permi No, Issuance Date Mailed Detivered <br /> APPLICANT—RETURN ALL COPIES TO: ., ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />