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«. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFIt USE: APPLICATION <br /> ` (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER UAUTYy.. #­,,. r».nh .� <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 Sw Joaquin County Ordnance �. 1,8 a t rules and regulations of the San J a uin Lo al Health District. <br /> Exact Site Address I ! / City/Town <br /> Owner's Name Phone <br /> Ad d ress City <br /> Contractor's Name License 6PZ1 Business Phone <br /> Contractor's Address Emergency Phs/Phone ) <br /> ,I <br /> Is Certificate of Workman's Compensation Insurance an File With SJLHD? Yes No <br /> TYPE OF WORK (CRECK): NEW WELL DEEPEN ❑ RECONDITION❑T DESTRUCTION❑ <br /> WELL CHLORINATION ❑. A WELL ABANDONMENT-0_ —OTHER.El— PUMP INSTALLATION PUMP REPAIR❑ �1 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank C1 Sewer Lines/29e9'� Pit Privy + <br /> As Sewage Disposal Field Cesspool/See age Pit Other <br /> 4 Property Line Private Domestic Well ) Public Domestic Well <br /> INTENDED USE TYPE OF WELL j <br /> y❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 2-.1"Ale - <br /> Y�l DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> '❑`DOMESTIC/PUBLIC DRIVEN Gauge of Casing f <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Q 4_ <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL SLjfface Sea I tailed B <br /> PUMP INSTALLATION: Contractor lkodf <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 11State Work Done <br /> PUMP REPAIR: ❑ State Work Done i <br /> DESTRUCTION OF WELL: Well Diameter we imate Depth <br /> Describe Material and Procedu <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 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 ll for a Grout Inspection prior to grouting and a final inspectiop. t <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Revere Side) .k s <br /> X � <br /> FOR DEPARTMENT USE ONLY i <br /> PHASE'I r t ) <br /> Application Accepted By - Date <br /> Additional Comments: <br /> Rasit Grout Inspection �" h�a Iff11 al Inspection [I{i <br /> inspection Date (� Inspection By C/�uu Date <br /> � I <br /> Fee Is Due: 13 ANNUALLY El PER UNIT El PER SITE ❑ EACH ❑ January 1 8,Received ey 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 Sg <br /> LESS % J. <br /> ,\PRORATION <br /> PLUS <br /> PENALTY t <br /> OTHER f"""__4 <br /> OTHER '� E <br /> t <br /> Received by Date Receipt No. Permit No. I uan a Date_ Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />