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Application iii ' -Prdt�J36WkdWhen Submitted ProperlyCompleted. BeSureToSign TneApplication. <br /> FOR OFFICE USE: <br /> APPLICATION <br /> SAN JOAQUIN L(Pa*n-Transferable, Revocable, Suspendabie) PUMP&WELL' <br /> HEALTH DISTRIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) - WATER-..QUALITY �f ✓� <br /> Application is hereby m o the San Joaquin Local Health Districtfora permitto constr rei4rr e .This application is <br /> made in compliant ith San Joa ui ount Ordinan No. 1882 d the rule re do of the San,Joagy{n(Local Health District. <br /> Exact Site Add S I y/Town C'tZJ <br /> Owner's Name <br /> yOL �G»✓ 1r�" �� C"a` Phone <br /> Address City <br /> Contractor's Name Up a, Busine s�Pha <br /> Contractor's Address 'mergency Phone <br /> Is Certificate of Workman's Compensation Ia on File With SJLHD? Yes ✓ No <br /> nsura <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®-' PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> a <br /> DISTANCE TO NEAREST: Septic Tank pvfer Lines Pit Privy �'^� <br /> Sewage Dispos�I�Yeld T Cesspool/ page Pit Other i <br /> Property Line // ''�7""'' Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1,6?// <br /> ❑ II OUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 19"DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION &-I�OTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALface Seal I alled 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 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 0 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. p <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 hi r' g or sub-c acting signature certifies the following:"I rtify that in the performance of the work forwhich this <br /> perm s d, I shall plo persons subject to workman's comp ation laws of California." <br /> out in ction prior 1p grouting and a finalinsp ion. <br /> Signed X Titl _ Date: <br /> (Draw Plot Plan On Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection he Ill FI i Inspection / <br /> Inspection By P Date !" Inspection B Date <br /> Fee Is Due: 11 ANNUALLY El PER UNIT ❑ PER SITE C1 EACH ❑ January 1 &Received By January 3 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASF EXPLANATION BILLING REWTTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> G�� 10`7� �/ 7.t/•Zy <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 _ <br />