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Applications Will Be Processed When Submitted Properly Completed. a ure orn <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY s <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thrk herein described,This application is <br /> e work <br /> made in compliance with San Joaquin County Or ance NO.186 and the rules and reg lations of the San Joaq. ' ocal Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name City .-- <br /> Address 0 nse Business Phone <br /> Contractor's Name <br /> # — <br /> Emergency Phone � g <br /> Contractor's Address No �J ` <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes y <br /> TYPE OF WORK (CHE=CK): NEW WELL[3 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAI5^ > <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines - � y <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Field t7 <br /> Property Line Private Domestic Well <br /> Public Domestic Well a <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> E] DOMESTIC/PUBLIC <br /> 13 DRIVEN Gauge of Casing ,f <br /> 11 IRRIGATION 11 GRAVELPACK Depth of Grout Seal I <br /> 11CATHODIC PROTECTION ❑ ROTARY Type of Grout xl <br /> li ❑ DISPOSAL ❑ OTHER + Other Information <br /> ❑ GEOPHYSICAL i Surface Seal Installed By: <br /> t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump ' P H.P. <br /> PUMP REPLACEMENT: 51 State Work Dane <br /> ❑ State Work Done <br /> PUMP REPAIR: `t_ Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material And Procedure y <br /> � <br /> I hereby certify fh`at_"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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work.for which this permit <br /> is issued, 1 shall not employ any person in such mariner 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 thd-performance of the work forwhich this <br /> permit is issued, l shall employ persons subject to workman's compensation laws of Califbrn <br /> I will call for a Gr I ction�r' r to grouting and a final inspection. <br /> \. Date: .— <br /> Title: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> I -FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date —0"1. <br /> Application Accepted By IAV1� r <br /> Additional Comments: ..._ . _ 'ion <br /> µ PhaseJi Grout-Inspectlon' <br /> -inspection'By Phase 111 Final Inspect ' <br /> "'__ Date Inspection By ate <br /> - , <br /> Fee Is Due: ❑ ANNUALLY - 13 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 C1 Juiy 1 &Receiv REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE- EXPLANATION DATE DATE REMITTED - AMOUNT <br /> ! (� S ao <br /> FEE T�.•0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> 1�[ OTHER <br /> OTHER <br /> Delivered <br /> - Received by Date <br /> Receipt No., Permit No. ssuance Date _ Mailed <br /> F APPLICANT—RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 . STOCKTON,CA 95201 <br />