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4 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign ' scion: <br /> FOR OFFICE USE:-. APPLICATION <br /> (For Non-Transferable,'Revocable,Suspendabie) PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN RIPLICATE) WATER-QUALITY, <br /> Applicationish e,by made to the San Joaquin Local Health District fora permit to construct and/or install the work hereinesced-This application is <br /> made in comp r,nce with San J aquin County Ordinance No. 1882 and the rt{les and regulations of the San Joa uin Local Health District. <br /> b :X J e <br /> Exact Site At ,ress k City/Town <br /> ` Owner's Nle " Phone <br /> Address -2 <br /> City^" O <br /> Contractor's Nameicense#' Business:P.hone=: <br /> Contractor's Address Emergency Phone ` 'T.. *` = <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes C% No <br /> TYPE OF WORK (CHECK): NEW WELL❑'� DEEPEN ❑ RECONDITION 13 - 'UDESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2- PUMP REPAIR <br /> REPLACEMENT G- , <br /> DISTANCE TO NEAREST: Septic Tank �I ��P Sewer Lines fait Privy <br /> i Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line I Private Domestic Well - Public Domestic Well <br /> INTENDED USE TYPE OF WELL 5 <br /> ❑ INQOTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ? *� <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing o <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL; ❑ OTHER Other Information 3 <br /> 0 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor/vc� iya <br /> Type of Pump H.P. s <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done rJ <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 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 all t G Ins esti n wl o groutin nd a final inspection. <br /> Signed _ Title: r Date: <br /> (Draw Plot Plan on erse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE l k <br /> Application Accepted Date <br /> _. S <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phasg-W Fin I Inspection <br /> Inspection By Date Inspection By Date. /,I s d� - <br /> 1 <br /> Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE 'ITEACH ❑ January 1 &Received By January 31' ❑ July 1 &Received By July 31 <br /> REMIT i <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED j <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS 4 <br /> PRORATION <br /> PLUS s I <br /> PENALTY = t <br /> OTHER <br /> OTHER <br /> Received by -Date- Receipt No. ,^'�-�•'�_-�Permit No. _ .„ .,lafsuanceDate _ Maited- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2OD9 STOCKTON,CA 95201 <br />