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Applicatipns Will$e Processed When Submitted Properly Com t B Se`�Tp to7pplicat I ion. ` <br /> APL'IA tc�� <br /> FOR OFFICE USE;; 4 @-A <br /> -(For Non-Transferable,Fevo 'Ia , S4spendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HE PA51MI-C1 1980 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t fir, I <br /> Application is hereby made to the San Joaquin Local Health District for a permit to(5onsigFt4nq/,6r+glii�rtAeWor ereindescribed.This application is <br /> made in compliance wit: aft),Jp�djuin my Ordinanc No. 18fi2 nd rules �a�tibr�s�f �$�� In Local �alth istrict. <br /> Exact Site Address .. `�`r City/Town <br /> Owner's Name Z)° ` L Phone <br /> Address City <br /> Contractor's NameL`7� � �� License# �7 Business Phone zrf <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 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank � Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Linel Private Domestic Well Public Domestic Well <br /> INTENDED USE f TYPE OF WELL _ f <br /> ❑ INDUSTRIAL 0 CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑I 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 /> } <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Don <br /> PUMP REPAIR: State Work Don <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 rulesiand 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 h' ' g or sub-contracting signature certifies the following:1 ce ify that in the performance of the work for which this <br /> per,I ed, I shall emplo s subject to workman's comp n laws of California." <br /> I ill ut In pec on prio to grouttn and a final inspec i <br /> Signed X W Title: Date: <br /> (Draw Plot Plano Reverse Side)-- <br /> FORDEPA MENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date O f <br /> Additional Comments: <br /> i <br /> Phase 11'Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee is Due: C1 ANNUALLY ❑ PER UNIT PER SITE ElEACH ElJanuary 1 &Received By January 31 ElJuly l &Received By July 31 <br /> i I . BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMO UE CHECKED <br /> AMOUNT <br /> r <br /> FEE <br /> LESS 6 9e.4' 1 <br /> PRORATION Y— � a.f�. <br /> PLUS (] �' r 4 e <br /> PENALTY Azi <br /> OTHER <br /> O � A <br /> OTHER <br /> 67 1;.16 <br /> Received by Date - Receipt No. Permit No. .-- -Issuanc Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES _1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 — <br />