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Applications Will Be Processed When Submitted Properly Completed.Be S e-,4p <br /> a r <br /> FOR OFFICE USE: APPLICATION <br /> 3 <br /> (For Non-Transferable,Revocable, Suspe le PUMP& <br /> ENVIRONMENTAL HEALTH OEE, <br /> QV 3 1981 <br /> 4 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 1 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or NIthf + lh(�1�, (ryj s"'bfted.Thisapplicationis t <br /> made in compliance withlS J a ount di ance No. 1862 and the rule re ulations c(f�ita � a�ilJ int I > I"Re t t <br /> Exact Site Address / l � L City/Town <br /> Owner's Name } v Phone <br /> Address / 1 / City <br /> Contractor's Name y`T f Licerise# Bus' ess Phone <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 ABANDONrENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ � <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy 1 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other . <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ,❑,.,..,, D/INNDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> Lg' OMESTIC/PRIVATE ❑ 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 /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done '= <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 /> 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 subje orkman's compensation laws of California." <br /> Contractor's h or sub-con c g signature certifies the following:"I c i hat in the performance of the work for which this <br /> per is issu I h II ern y pe ons subject to workman's compens t' laws of California." <br /> f II cal Ins p tion p ' r to ting and a final inspecti t ] <br /> Signed X D Tltle: Date: l/ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY Q <br /> PHASE I � <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection P 1a5e 111 F'nal Inspection } 5� <br /> Inspection By Date Inspection By '-t Date <br /> Fee Is Dile: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ nuary 1 &Received 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 /> OTHER <br /> Received by Date - Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.801 2009 STOCKTON,CA 95201 <br />