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Applications Will Be Processed When Submitted Properly Completed. Be u, r7i Th iicatian. <br /> FOR OFFICE USE: APPLICATION �; <br /> (For Non-Transferable, Revaca ur <br /> 1:� PUMP&WELL <br /> COMPLETE IN <br /> ENVIRONMENTAL HEASY R�� 19a� <br /> ( TRIPLICATE) Q <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or irls# IwbY - `I� describe . <br /> n r i an o. This application is <br /> made incompliance wit �loaquin 1862 and the rule ,n'd r�Ju i l s i�S � a i oc 9, Di rict- <br /> Exact Site Address / / U G� $114"win <br /> Owner's Name Phone <br /> Address Q + <br />_ City <br /> Contractor's Name License# Busine hone <br /> Contractor's Address y � � Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C16 <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 /> ❑ 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 Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ✓ 17-state Work Done I <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> F <br /> Describe Material and Procedure <br /> t <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 thework forwhictl this permit <br /> is issued, I shall no mploy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contrg orsub-contracting signature certifies the following:"I y that in the performance of the work for which this <br /> per it5�­ I shallemp y per ct to workman's com nsa ' n laws of California." t <br /> r Insp ion p i Anssubr <br /> ting anda sinal inspe n. �- <br /> Signed X Till Date: <br /> (Draw Plot Plan n Reverse Side) <br /> 3 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I11 <br /> Application Accepted By � � 1 Date <br /> Additional Comments: <br /> P e II Grout Inspection se III F'nal 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY j <br /> OTHER <br /> OTHER <br /> i o <br /> Received by Date Receipt No, Permit No. Is ance ate I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO;. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />