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fteetiO /J <br /> Applications Will Be Processed When Submitted Properly Completed. Be Su t+ p (I/�J`! <br /> APPLICATION <br /> F(A OfF�E-USE: ((�� a <br /> (For Non-Transferable, Revocable, Suspen �}1 �� '0 BUMP&WELL <br /> G ' ENVIRONMENTAL HEALTH PER <br /> r\ <br /> ENVIRONMENTAL(COMPLETE IN TRIPLICATE) WATER QUALITY t ��t ,C�t <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instalt��l&�n+ JTf -"i d4scribed.This application is r <br /> made in compliance with San Joaquin C nt Ordinance No. 1862 an the rules and regulations of the J aquln ocal Health District. <br /> Exact Site Address <br /> D fCity/Town <br /> r r <br /> Owner's Name �` Phone <br /> Address n / 49 City— <br /> License <br /> Contractor's Name License# P Business Phone ly.' <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No {f\ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <br /> WELL CHLORINATION 13WELL ABANDONMENT-0 OTHER 11PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ `I <br />—DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 1 .. Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> DUSTRIAL 11CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal "7! <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ( Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 7Eli_ <br /> Type of Pump n �' -V)/— , <br /> ❑ State Work Dane �-Q� J 1 <br /> PUMP REPLACEMENT: ;�--�����on f <br /> PUMP REPAIR: ❑ State Work Done <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 /> 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 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 or a Grout Inspe ion prior to grouting and a final inspection. J (� <br /> - Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR PARTM NT USE ONLY <br /> PHASE f Date <br /> Application Accepted By <br /> Additional Comments: <br /> has1 Grout Inspection Ph a IN Final Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> x <br /> nI <br /> "Fee IS Due: ❑ ANNUALLY ❑ PER UNIT El PER PER SITE ❑ EACH ❑ January t &Received By January 31 July 3 &Received By July 37 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ¢(f <br /> LESS <br /> y PRORATION <br /> PLUS I <br /> PENALTY 1 <br /> OTHER { <br /> OTHER <br /> I Issuance Date Mailed Delivered <br /> gate- rt-Receipt No. Permit No <br /> by �.-� �„ <br /> . _ APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P-O.Box 2009 STOCKTON,GA 201 _ <br />