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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR or=Flce USE: APPLICATION lu �. <br /> For Non-Transferable, Revoca � �.. <br /> PUMP&WELL <br /> ENVIRONMENTAL HEA 4a IT <br /> (COMPLETE IN TRIPLICATE) WATER QUALIT <br /> Application ishereby made tothe San Joaquin Local Health Districtforapermit toconstruct and/o install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and re ulaio s,Pj�t Ejw ocal Health District, <br /> Exact Site Address /� A -HLirTU 11 OW D��� <br /> Owner's Name Phone <br /> Address S _ City <br /> Contractor's Name License Business Phone f7� <br /> Contractor's Address Ot L 2.2 7 Emergency Phone 7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No I) <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION El DESTRUCTION❑- <br /> WELL CHLORINATION F-1WELLABANDONMENT ❑ OTHER 11PUMP INSTALLATION yCJ� PUMP REPAIR❑ <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_11' I <br /> ❑ INDUSTRIAL ❑ CABLE TOOL T Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing l <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: Vill5tate Work Done t <br /> PUMP REPAIR: ❑ State Work Done --•� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure J <br /> r� <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. I <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 compensatipn 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 for a Grout Inspection prior to grouting and a final inspection. .r7 <br /> Signed X &'J Title: )22_ fel Date: I a.2'00/ <br /> (Draw Piot Plan on Reverse'Side) j <br /> FOR DEPARTMENT USE ONLY <br /> PHASE n l <br /> Application Accepted By. ^�- �`�► Date' 40-0 <br /> Additional Comments: 11' <br /> Phase II Grout Inspection e ill Final Inspection �� I <br /> Inspection By Date Inspection Veceived <br /> Date <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH El January 1 8 By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> CC AMOUNT <br /> FEE L J� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER ' <br /> f. <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance batBI Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />