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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabfe) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joh uin Count�Ordinance No.186 n the ul and regulations of the San Jin Lgca Health District. <br /> Exact Site Address ��� r / City/Town <br /> Owner's Name Phone <br /> Address City- <br /> Contractor's <br /> ity Contractor's Name icer a -�!~?1� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation I,n,,surce on Fife With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL[5 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ — d <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST' Septic Tank 1400--dr- 'Sewer Lines AdD / Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Z9Q Other <br /> I Property Line/0 Private Domestic Well�� Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 0'I DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 1fY666ESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> 6`I60MESTIC/PUBLIC ❑ DRNEN,_ r Gauge of Casing I <br /> ❑#IRRIGATION ❑ RAVEL PACK Depth of Grout seal 4522 <br /> ❑ CATHODIC PROTECTION 92-IR OTAhY'.. y a y4 Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 0 <br /> ❑ GEOPHYSICAL �u,rface Peak Installed By: ^F <br /> PUMP INSTALLATION: Contractor �� / �.- <br /> t Type of Pump �/� H.P. �**- <br /> PUMP REPLACEMENT: .- 0.State Work Done - i <br /> PUMP REPAIR: ❑ State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth m <br /> f 1.. <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application,and that the worWwill be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich this permit <br /> is issued, I shall clot 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 call for a Grout Inspectioporio�io:gro thng and a final inspection. <br /> Signed X € Title: Date: <br /> 1 (Draw Plot Plan on Revers ide) <br /> I FOR DEPARTMENT USE ONLY <br /> PHASEI i <br /> Application Accepte By ' Date <br /> Addiliortal Commen <br /> Ph e I �rroujAnspection I Fi Inspection <br /> Inspection By Date �3 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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATIONAMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> pD o� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> o <br /> Received by Date 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 />