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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE:- 9 APPLICATION <br /> (For Non-Transferable, Revocable,S e <br /> PUMP&WELL <br /> ENVIRONMENTAL <br /> (COMPLETE IN TRIPLICATE) Wi �1 1:1TY O <br /> Application is hereby madetothe San Joaquin Local Health Distric a�Itoconsti;wx /orinst�Iltheworkhereindescribed,Thisapplicationis <br /> made in compliance with Sp oa�n C Ordinan e No. i8 ,�r1 the rui n%Ugulatione)QfVre San Joa uin Local HntILD ri <br /> Exact Site Address { r�wn �""``ZZ33 <br /> Owner's Name �/C/ �' G J 1r � \1 hone 7 '7 y <br /> Address City Q <br /> Contractor's Name ense# 3� Busiinee�ss P on <br /> Contractor's Address L'� `' ' Emergency Phone `T <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ / t ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 91-""' <br /> � <br /> REPLACEMENT❑ <br /> 4 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other x <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 Weil 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 Dane <br /> Af <br /> PUMP REPAIR: 5yState Work Do <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 n6 employ any person in such manner as to become subject to workman's compensation laws of California." Q <br /> Contrac or sub-contracting signature certifies the following:.I cc that in the performance of the work for which this r� <br /> per i s <br /> 11 h empl pe ons subject to workman's compensto laws of California." v ! <br /> I lie 1 o n ectl pri ro ng and a final inspectio <br /> Signed X Title: ;�� Date: j <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY t <br /> PHASE I 9- r �� <br /> Application Accepted By '� l 4 [ _ Date b <br /> Additional Comments: <br /> Phase 11 Grout Inspection h e III F' al Inspection <br /> ,Inspection By R.C1 i n Date Inspection By Date LAS`R_ <br /> Fee Is Due: El ANNUALLY <br /> El UNIT ❑ PER SITE EACH ❑ January 1 &Received y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ,{�✓--�s <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No, Is uance to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 852 <br />