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w i atlonIjII Be Pr eQs ed V�ts1�Submitted Properly Completed.Be SureTosign tneAPPttcauon. <br /> FOR OFFICE USE: " 18 APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> m <br /> sm <br /> R6?RQNMENTAL HEALTH PERMIT <br /> IRM DiWATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtfora.permittoconstructand/orinstallthework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and th 7L:,c <br /> ules and re lations of the San JoaquinrH�alth District. <br /> Exact Site Address �� City/TownPhone <br /> Owner's Name � CityAddressContractor's Name # _ Business Phone i 2 Contractor's Address 1C� �^ ergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> (� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ ' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT El OTHER El PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> i ❑ INDUSTRIAL ❑ CABLE TOOL Dia'of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 0 IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I � ac Seal Installed By: �y <br /> PUMP INSTALLATION: Contractor P v <br /> .Type of Pump <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 /> hereby certify that I have prepared this application and that the work will be done in accordance with San JoECountyy, <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 performance of the work for whiis issued, I shall not employ any person in such manner asto become subject to workman's compensation laws Contractor's hiring orsub-contracting signature certifies the following."I certify that in the performance of the workpermit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wii call for rout Inspection prior to grouting and a final inspect' Date: <br /> '�->! ns�� ` Title: <br /> Signed X scT —r <br /> (Draw Plot Plan on Reverse Side) s <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date 1` IDOL— <br /> Application Accepted By <br /> Additional Comments: <br /> Phase tl Grout Inspection as 411 Final Inspection <br /> Date . Inspection By Date <br /> Inspection By 3 ,( <br /> ` Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Janu�1 [] July 1 &ReceivedREMIT 31 <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 /> q3Delivered <br /> 7 <br /> ed <br /> Date Receipt No Permit No. - Issuance Date. t' Mailed <br /> Receivby <br /> APPLICANT—RETURN ALL COPIES TO'. ENVIRONMENTAL HEALTH PEAMITlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />