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r Applications Will Be Processed When Submitted Properly Completed. Be SureTo sign 1neAppncauon. <br /> FOfi•SF"rTCE USE: <br /> ^- - APPLICATION n <br /> (For Non-Transferable, Revocable,Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t (COMPLETE IN TRIPLICATE) WATER QUALITY n is <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. s applic <br /> This atio <br /> made in compilance with San Joaquin C my Ordinance No. 86 and the rules and regulations of the San oagl1n LHealth District. <br /> Exact Site Address , City/Town _ = <br /> f 1! <br /> r Owner's Name Phone <br /> _. 1City <br /> AddressContractor's Name &eMZ�rXLicense# Business Phone <br /> Contractor's Address Emergency Phone <br /> 1s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL IS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ wri <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ l" <br /> REPLACEMENT❑ f � � <br /> 1 DISTANCE TO NEAREST: Septic Tank Sewer Lines e 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 /> to <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 1 <br /> ❑ IRRIGATION �GRAVEL PACK Depth of Grout Seal � <br /> k ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> 4 PUMP REPLACEMENT: ❑ state Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth "permit <br /> H <br /> Describe Material and Procedure 3 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San <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 foris issued, l shall not employ any person in such manner as to become subject to workman's compensation laws of Californa. <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 subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> �. .. �/ Title: 1NI Date: r G— 06 <br /> Signed X «1 —_ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> lk PHASE I `�/ZZ,�O <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Kase k Fi I Inspection <br /> t Phase 11 Grout Inspection Date — <br /> Inspection By _ <br /> Date In io <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT ElPER 51 E ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION G EMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> r <br /> LESS <br /> f PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ! OTHER <br /> t Receipt Na <br /> Receivetl by Date Permit No. iss ante ate Mailed - Delivered <br /> I TON AVE.,P.O.box 2009 STOCKTON,CA 952 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI.SERVICES 1601 E.HAZEL <br />