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A�tions Will Be Processed W I: ubmilted Properly Completed.Be Sure To Sign The Application. <br /> J <br /> FOR OFFICE USE: 12)' <br /> n { <br /> �+E`p � � ,Ey62 2 APPLICATION <br /> (For Non-Transferable, Revocable,'Suspendable) PUMP&WELL <br /> r SAN JOPQUIN WstONMENTAL HEALTH PERMIT <br /> HEALTH DISTRICT WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work herein described.This application is <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 a7 0Q fz)POS 4, City/Town <br /> Owner's'Name o w f Phone <br /> Address City <br /> Contractor's Name u License# C� Business Pho <br /> o� ne_ 7�1}7 _ k <br /> Contractor's Address / '�'' Emergency Phone <br /> (" <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes "IA-�— No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ T <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> v <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL pia. of Well Excavation <br /> X 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: ' ' <br /> ❑ State Work Done <br /> PUMP REPAIR: 5Z State Work Done 0at "~ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth l <br /> Describe Material and Procedure <br /> r <br /> 0 <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 forwhich 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, l shall employ persons subject to workman's compensation laws of California." <br /> I Wil lZfo a Grout In tion or to grouting and a sinal inspec ' <br /> Signed X - Title: Date: . y <br /> * ) (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By �' Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P ae I Final Inspection <br /> Inspection By Date Inspection By � nDate �z7 " <br /> Fee Is Due: 11ANNUALLY ❑ PER UNIT ❑ PER SITE [IEACH C3January 1 &Received By January 31 Cl 3uay 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE �� a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 <br />