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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> made in compliance wit�h+5 o ul unty i nce No. 186 �a'nnda�th rule nd regulations of the San uyn Loc a t District. <br /> Exact Site Address —! G' J Y" �A!'�` -e City/Town <br /> Owner's Name /f � 'r r Phone ill <br /> r <br /> Address 1 City 11 <br /> Contractor's Name W, dt 1 cense Business Phone <br /> Contractor's Address Emergency Phone IM <br /> Is Certificate of Workman's Compensation In urance on File With.SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPUL El RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMEOTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ `—✓ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> 4 Property Line Private Domestic Well Public Domestic Well IM <br /> S INTENDED USE 1, TYPE OF WELL <br /> ❑ INDUSTRIAL I ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE II ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing Ip, <br /> ❑ IRRIGATION i ❑ GRAVEL PACK Depth of Grout Seal �M <br /> ❑ CATHODIC PROTECTION !� ❑ ROTARY Type of Grout IM <br /> ❑ DISPOSAL ,I ❑ OTHER Other Information W <br /> ' <br /> 11 GEOPHYSICAL Surface Seal Installed By: �M <br /> PUMP INSTALLATION: i, Contractor IIM <br /> . Type of Pump H.P. IM <br /> PUMP REPLACEMENT: ;� ❑ State Work Done �M <br /> PUMP REPAIR: II ❑ State Work Done IM <br /> OWell Diameter <br /> Apopr�ox�inepth DTO � <br /> Describe MaterialInd Procedure �sr6E' "-00 <br /> I hereby certify that I have prepar 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 whicrh 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will r Grout Inspection prior to grouting and a final inspection. <br /> Signed X � Date: ef <br /> (Draw Plot Plan on Reverse Ide) I` <br /> y FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By ut, � Date <br /> Additional Comments: <br /> Phase II Grout Inspection ? Phase 1 I ection <br /> ,I <br /> Inspection By Date Inspecti n By b <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE © EACH ❑ January 1 &Rec I July 31 <br /> RE IT <br /> i BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED III <br /> AMOUNT DUE C ED <br /> FEE �////7 NT <br /> 7 J .l 0 3r O_IC <br /> LESS I� <br /> PRORATION I <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER _ i IIID <br /> -moo <br /> xReceived by Dat Receipt No. Permit No. Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMIT/SERVICES.­.-_ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />