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Applications W rage d-Wh S bm!tied Properly Completed. BeSureToSignTheApplication. <br /> FOR OFFICE USE: }� PLICATION <br /> (For Non- r r able, Revocable, Suspendable) <br /> PUMP&WELL <br /> MAR 4 E"50 NTAL HEALTH PERMIT 40/ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the SaaapfgLji7,l <MllHVlthX strygtforapermit toconstruct and/or install the work herein described.This application is <br /> made in compliance wl n o ui rd q 62 and the rules and regulations of the San oa uin Low Heal h District. <br /> Exact Site Address �� g City/TownTC��� <br /> Owner's Na Z ""� C'� 1�� Phone 4 7—� <br /> Address ,4City <br /> Contractor's Namep License# 7 Business Phone <br /> Contractor's Address �' Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes '� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L+J� <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 Wel! Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY f Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 7 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: tate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that l 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 cer V y that in the performance of the work forwhich this <br /> per I shall em loy persons subject to workman's compens laws of California." <br /> will a rout ! pecti n prior io grousing and a final inspecti j/ � <br /> Signed X Title: Date: �/ <br /> (Draw Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY <br /> j PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P a e Ill Final Inspection <br /> Inspection By A IA� Date Inspection By Date In 77Z-4--Fd l <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION ,DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE Z y s <br /> LESS 1 <br /> PRORATION <br /> PLUS Y� <br /> 1 PENALTY <br /> OTHER <br /> ` OTHER <br /> : V ? 0 <br /> Received by Date Receipt No. Permit No. I uan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.8ox 2009 STOCKTON,CA 95201 <br />