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Applications Will Be Processed When Submitted Properly Co ed'-Betu'r To Sign The Aw4ation. <br /> FOR OFFICE USE: APPLICATIO {+,I II pq <br /> (For Non-Transferable, Revocable, Suspende!WUk 2 8 1981 <br /> - � <br /> ENVIRONMENTAL HEALTH E I�t�i�:QUI[4 t_00AL PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT <br /> Application is hereby made to the San Joaquin Local Health District for a permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862-and�the rules and regulations of the Sany ooaaq jn Local Health District. <br /> Exact Site Address �4TO r-tJ �i� City/Town <br /> Owner's Name r Phone <br /> Address _ li7, 11� W&79�110115 AM City <br /> Contractor's Name License# usin ss Phon 'e7 � <br /> Contractor's Address d Emergency Phone/ ©L r� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No J <br /> S TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ (� <br /> i WELL CHLORINATI ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C] <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 <br /> INTENDED USE TYPE OF WELL { <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br />"r ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC _� DRIVEN '. Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY f Type of Grout <br /> i ❑ DISPOSAL ❑ OTHER '` Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump �t•'�f _ H.P. <br /> UMP REPLACEMENT: 11 State Work Done <br /> PU ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ' Approximate Depth <br /> Describe Material and Procedurep <br /> I hereby certify that I have prepared this application and that tFae 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 ar licensed agent's signature certifies the following:'1 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 sub' t to workman's compensation laws of California." <br /> I I for a Grout pectio rior to uting and a final inspection. <br /> F Signed X D— Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Q� Date I_ "l <br /> Additional Comments: <br /> Phase II Grout Inspection II Fina nspectiony / <br /> Inspection By Date Inspection By t/' ate tJ r <br /> Fee Is Due: ❑ ANNUALLY ❑ PERrUNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE `—_'t <br /> s <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I <br /> Received by! ,. Date Receipt No. Permit No. Issu ce Dat Mailed Delivered I <br /> i .APPLICAf �RETURN ALL-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bpr 2009 STOCKTON,CA 95201- ,r <br />