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f Applications Will Be Processed When Submitted Properly Completed. Be Sure o gn/ e <br /> FOR oFFlce usE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) I PUMP&WELL <br /> ENVIRONMENTAL-HEALTH'PERMIT <br /> WATER QUALITY, ,� .;,., _ �� -y4- <br /> (COMPLETE IN TRIPLICATE) ^ <br /> Application is hereby made to the San Joaquin Local Health District for<a.permit to construct and/or installthe work herein described.This application is <br /> made in compliance wi h San Joa in County Ord -ante No. 1862 and they rules andregulationsof the San Joaquin Local Heal h District. <br /> , � City/Town <br /> Exact Site Address <br /> c Phorie <br /> Owners'Nartte y k City— � � <br /> Address t`' <br /> t <br /> "+ License#ISIBusiness Phone <br /> Contractor's Name � <br /> Contractor's Address .— 'Emergency Phone <br /> l Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No j <br /> TYPE OF WORK {CHECK): NEW WELL❑ DEEPEN ❑ 'RECONDITION❑ DESTRUCTION,❑/� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> Sewer Lines Pik Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> f Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I ❑ DOMESTIC/PRIVATE k ❑ 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 /> 0 DISPOSAL r ❑ OTHER Other Information <br /> r ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> r Type of Pump Fi.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 1 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. f� <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework for which this permit <br /> is issued, 1 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ill ca for a G out Ins p c' tpj1br to grouting d a final inspec! . - <br /> # ,.e '4 Dat <br /> l Signe 1 Title: w <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �t1.l :ter F Date <br /> Application Accepted By \711r!✓v <br /> I Additional Comments: <br /> rPhase II Grout inspection P asIII Final pection <br /> Inspection By <br /> Date Inspection.By Date <br /> Fee Is Due: 1:1'ANNUALLY El PER UNIT ❑ PER SITE El EACH -❑ January'l &Received8y January 31 ❑ July 1 8 fleceiveRdEMITuiy 31 <br /> BASE EXPLANATION BILLING REMITTANCE - - $ -- AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ifs <br /> LESS } <br /> PRORATION - <br /> t PLUS <br /> PENALTY. .. - <br /> OTHER <br /> OTHER <br /> ^ <br /> r Date- Receipt No Permit No. [• - Is ante to Mailed Delivered <br /> Received by <br /> SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STDCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/ <br />