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Applications Will Be Processed When Submitted Properly Complete �IStuirVgn The Application. <br /> FOR OFFICE USE: APPLICATI(For Non-Transferable,Re vendable) <br /> ENVIRONMEN t W� <br /> HPE <br /> Q PUMP&WELL <br /> --1$ <br /> (COMPLETE IN TRIPLICATE) WA T ;r'on,�4ructand/ <br /> TY � oc, ` <br /> Application is hereby made to the San Joaquin Local Health District for aper 0� , u�orkherein described,This application <br /> is <br /> made in compliance with San J a uin ounty Ordin cc No.1862 and the rules and regi@1iQn;`tx a San J aqui Lo al He Ith District. <br /> Exact Site Address `City/Town <br /> Owner's Name <br /> z N Phone <br /> Address City v <br /> Contractor's NameLicense# Bus'nes Phon <br /> Contractor's Address <br /> Emergen y Phone } <br /> Is Certificate of Workman s Compensation In rance on File With SJLHD? Yes A . No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ �] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPA.I4( ( � <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy I <br /> --,--Sewage Disposal Field <br /> ,If `Cesspool/Seepage Pit Other j <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation i <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED --" "Dia: of WeI1 Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL -- 13 OTHER Other Information <br /> ❑ GEOPHYSICAL - v - r Surface Seal Installed By: - <br /> PUMP <br /> INSTALLATION: <br /> Contractor <br /> Type of Pump <br /> H.P, G\ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Don IF <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 su -conIt racting signature certifies the following:"I certify that in the performance of the work for which this <br /> i <br /> permit is is ed, I mploy persons subject to workman's compensation laws of California." <br /> I will a G sp tior) prior to grouting and a final inspectie--� -'~moi <br /> ' v' <br /> Signed X Title: Dale: <br /> j (Draw Plot Plan on Reverse de)- <br /> ' _. , FOR DEP RTMENT US '.ONLY <br /> PHASE I a-'7 �O <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection / P 1 Final 1n coon . <br /> Inspection By Date Inspection B / i ate <br /> .rte <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 /> ( BASE EXPLANATION BILLING _ REMITTANCE $ AMOUNT QUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE C� <br /> LESS <br /> [[[ <br /> PRORATION <br /> PLUS <br /> PENALTY, <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> I " APPLICANT—RETURN ALL.COPIES TO! ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P}.Box 2009 STOCKTON,CA 95 .,— <br />