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- Applications Will Be Processed When Submitted Properly Complet re To Sign The Application. <br /> FOR OFFICE USE: APPLICATI <br /> �4 4 <br /> (Far Non-Transferable, Re I 9�Isp In <br /> ENVIRONMEN L PUMP&WELL <br /> TH P ��IT <br /> (COMPLETE IN TRIPLICATE) UALlTY <br /> Application is hereby made to the San Joaquin Local Health Districtftathe <br /> mite structan /O� the work.herein described.This application is t <br /> made in compliance with SanJoaqui County Ordinance No. 186rules and Sgt `ti ;o e San Joaquin Local Health District. <br /> Exact Site Address 0 �__ ���� ity/Town <br /> Owner's Name <br /> Address City <br /> Contractor's Name License# 1_�,?Z3 Business Phone <br /> Contractor's Address Emergency Phon <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 CHLORINAT ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ Q <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 `i' -TYPE OF WELL <br /> ❑eNDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation � <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing e <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 O <br /> ..T,yy e of Pump H.P. <br /> PUMP REPLACEMENT: I=J"State Work Dane �tj� <br /> PUMP REPAIR: i T]-State Work Done + <br /> DESTRUCTION OF WELL: F :: Well Diameter <br /> Approximate Depth nt <br /> Describe Material and Procedure 'S <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 1 <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. <br /> Signed X _ J - __Title:...._ ._.. Date:17 <br /> (Draw Piot Plan on Reverse ide) <br /> RD ARTME T USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase I Fi Inspection ` <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER-UNIT PER SITE ❑ EACH ❑ January 1 &Recei d By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED _ <br /> DATE DATE REMitTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> S <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> '''=�'_° APPLICANT`RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />