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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> P;FR dFICE USE: APPLICATION .; �`�` p {For Nor,�-Transf4r`abie, Revocable,Suspendable} <br /> PUMP&WELL F <br /> ENVIRONMENTAL HEALTH PERMIT .� <br /> 2^ 1. 4, WATER QUALITY N ; <br /> {COMPLETE IN TRIPLICATE) - <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 with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joa in Local Health'District.'' <br /> Exact Site Address �� � / � .City/Town <br /> Owner's Name Phone ' <br /> Address City a <br /> Contractor's Name License# Business Phone <br /> _ O _ <br /> Contractor's Address '` Emergency Phone <br /> Is Certificate of Workman's Compensation Insura ce on Fil ith SJLHD? Yes No T <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ —� <br /> WELL CHLORINATION ❑ WELLABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> YDISTANCE TO NEAREST: Septic Tank SeerwLines Pit Pit Privys <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE ,� S�TYPE OF WELL 0 <br /> ❑�,-�INDUSTRIAL„ --�-- ` --- 'CABLE TOOL Dia. of Well Excavation s� <br /> t <br /> E5DO•MESTIC/PRIVATE_-` ❑ DRILLED Dia. of Well Casing e= t <br /> ❑��D-OMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> 2-IRRIGATION - ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout / . - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICALf� +Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 'I : <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT Fe ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Donee r+ _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth rJ <br /> Describe Material and Procedure <br /> .il,,hereby certify that I have prepared-this application and that the work will be done in accordance with Sari Joaquin County <br /> ordinances,,state laws, and rules and regulations of the San Joaquin Local Health District. ' <br /> Home ow"b or licensed agent's signature certifies the follow[ng:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any persori in such manner as'to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub contracting signature certifies the"folIowing:"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 /> r w <br /> I will s fol a Grout Ins�e n for to grouting aril a final ins pecCan. <br /> Signed X <br /> r F Title: Date:,_/ <br /> Draw Plot Plan on Reverse Side) <br /> } FOR DEPARTMENT,USE ONLY <br /> 4 # <br /> PHASE] 0 Date <br /> Application Accepted By <br /> Additional Comment <br /> t Phps r ut-Inspection. ..... •— •\ Final Inspection <br /> rf l�f <br /> Inspection B ate�.� � Irispection By. r Date <br /> 4 Z_ <br /> r,Fee Is Due: ❑.ANNUALLY_ —❑,PER UNIT © PER SITE El EA + ❑ January 1-&Received By January.31..,' ❑ July 1 &Received By July 31 <br /> 4 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE w $ Y <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 00 <br /> FEE 00 r <br /> LESS <br /> PRORATION <br /> k PLUS <br /> PENALTY <br /> I BOTHER <br /> c - <br /> OTHER <br /> 1 <br /> Received 6yDate Receipt No Permit No. "' Issu nce.b to Mailed Delivered <br /> S A 1601 E.HAZELTON AVE.,P.O.box 2049 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE -�.:� _ j <br />