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Applications Will Be Processed WhenSubmitted PropertyGompleleu. ow ouiv <br /> i ^r 4f <br /> -x . <br /> APPLICATION <br /> FUR OOF� FICE USE: <br /> (For Non-Transferable, Revocable, Suspendable) 1) PUMP WELL <br /> ENVIRONMENTAL HEALTH PERMITS /2 <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY 7 �� d =6V� <br /> Application is hereby made to the San Joaquin Local Health District fora 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 Lo al Health District. <br /> Exact Site Address ` 7 City/Town <br /> 'ry <br /> ' Ice <br /> -p Phone <br /> lu <br /> Owner's Name <br /> Address City <br /> Contractor's Name r i� License# Business Phone <br /> Contractor's Address Y <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes � No <br /> TYPE OF WORK (CHECK): NEW WELL;X DEEPEN ❑ RECONDITION❑ DESTRUCTiON1 <br /> WELL CHLORINATION 11WELL ABANDONMENT ❑ OTHER ElPUMP 1NSTALLATIONA 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 <br /> 11 INDUSTRIAL El CABLE TOOL <br /> Dia. of Well Excavation lI <br /> 9 DOMESTIC/PRIVATE ,DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <br /> ❑ IRRIGATION X GRAVEL PACK Depth�of Grout Seal <br /> lei NZ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL rface Seal Installed By: e lix <br /> PUMP INSTALLATION: Contractor M <br /> Type of Pump ar ; H.P. f <br /> _ PUMP REPLACEMENT: <br /> 11 State Work Done I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter App oximate Depth <br /> Describe Material and Procedure <br /> ' 3 . <br /> I hereby certify4hat 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 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 forwhich this <br /> permit is issued, ! all employ persons subject to workman's compensation laws of California." <br /> !�tisk I will fo ut In on prior to grouting and a final insp !on. <br /> !Signed X Tit! _ pate: <br /> (Draw Plot Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By R <br /> F <br /> Add itionaf,Comments: p <br /> k r Phase 11 Grout Inspection I ns do <br /> Date <br /> Inspection By Date Inspection By <br /> ❑ ANN Y ❑ PER UNIT ❑ PER SITE ❑ EACH El January 1 &Received By January 31 , El 1 Received By July 31 <br /> Fee Is Due REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> PATE DATE REMITTED AMOUNT <br /> FEE <br /> 960 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Permit No. Issuance Date- Mailed Delivered <br /> Received by pate Receipt No, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL rON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />