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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OWICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> COMPLETE IN TRIPLICATE ^�a T -y..r- T R. LITY <br /> i Application is hereby made to the SanJoaquiritiocal Health District for aperMittoconstrucfand/or install the work herein described.This application is <br />` made in compliance it Sa Daquin Cot Ordina ce No. 186 and a rules ancj regulations of the S Joaquin Local Health District. <br /> F <br /> Exact Site Address un17 City/Town � _ <br /> Owner's Name hone <br /> Address VCity <br /> Contractor's Name. License#a1 Business Phone (• <br /> Contractor's Address A 7 _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes No 4 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN V--'RECONDITION DESTRUCTION❑ ` <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ `> ! <br /> DISTANCE TO NEAREST: Septic Tank9 -Sewer Lines Pit Privy - I <br /> Sewage Disposal Field Cesspool/See age Pit Other ? <br /> Property Line_430 Private Domestic Well N3 Public Domestic Well <br /> INTENDED USE TY�P �F WELL <br /> y ❑ Ir$PUSTRIAL El-CABLE TOOL Dia. of Wel! Excavation �lIL <br /> Ed—DOMESTIC/PRIVATE ❑ DRILLED pia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK r Depth of Grout Sea! <br /> a <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Y Surface Seal Installed By: T <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done r <br /> PUMP-REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: r Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> a <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 performanceof thework"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 /> t <br /> I will II for a-Grout-Ins t''on_p for to_grouting and a final inspection. fi <br /> Signed X Title: Date: r <br /> raw Plot Plan on-Reverse Side) <br /> FOR EPARTME T USE ONLY <br /> PHASE I 9 � � �°`{ <br /> Application Accepted By 11't-rr"� Date 79 <br /> Additional Comments: <br /> Phase II Grout Inspection h e III Final Inspection ; <br /> Inspection By Date inspection By _Date <br /> I Fee IS DUE: ❑ ANNUALLY ❑ PER UNIT " ❑ PER SITE ❑ EACH" - ❑ January 1 &Received By January 31 J�❑e-July?I &Received By July 31 - <br /> l - REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE GHEGKED - <br /> 06 <br /> AMOUNT <br /> FEE <br /> LESS — <br /> I PRORATION 4 <br /> t y <br /> "PLUS ' <br /> .PENALTY <br /> ' OTHER <br /> F OTHER j <br /> —y <br /> r 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.Box 2009 STOCKTON,CA 95201 <br />