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Applications Will Be Processed When Submitted Properly Completed.Be Sure To SignTheApplication. <br /> i1SE: APPLICATION <br /> (For Non-Transferable, Revocepie, f p le} PUMP&WELL <br /> ENVIRONME TIAL E�L H F <br /> � <br /> (COMPLETE IN TRIPLICATE) <br /> (COMPLETE (�O <br /> Application is hereby made to the San Joaquin Local Health Dist�it lora permitto orst 'and/orinstall the work herein described.This application is <br /> made in compliance with an Joaquin County Ordinance No.1YOP tt��rules�nd regula ��,�J the San Joaquin Local Health District. <br /> Exact Site Addr %ess �—�/Town <br /> e p <br /> Owner's Name "'} <br /> Phone <br /> Address ,0 <br /> A 3 I e:E41 City 29d� <br /> Contractor's Name cfT License# /Z 23 .3 Business Phone <br /> Contractor's Address _EE- 19 7 Emergency Phone l <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No G <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ REGOND ION 13 DESTRUCTION❑ <br /> WELL CHLORINATION C1 WELL ABANDONMENT 1:1 OTHER r 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 /> Property Line Private Domestic Well Public Domestic Well t <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing .1 <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 Depthgun <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joa <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 as to become subject to workman's compensation laws o <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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: Date: 2 Ibt�a <br /> (Draw Plot Plan on Reverse Side ; <br /> FOR DEPARTMENT USE,ONLY <br /> PHASE I QAt,19 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> 1BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> 00 <br />{ FEE 1 <br /> r{ LESS <br />{' PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 y' <br />