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Appl ea i, ns Witi"Be Processed Whe mltted Properly Completed.Be <br /> 2 Sure To Sign The Application. <br /> FOR OFFICE USE: <br /> .- APPLICATION 2S �6�' <br /> ` (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ._ <br /> SAN CIAQLJIN MENTAL HEALTH PERMIT ' <br /> HE LTH DIS 4� WATER QUALITY 7" ',,l ,. . <br /> (COMPLETE IN TRIPLICATE) 2 7 �. A 14 <br /> Application is hereby madetotheSan Joaquin Local Health Districtforapermittoconstructan Tori stalltheworkherein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 18 2 and the rules and regulations of the San.Joaquin Local Health District. <br /> Exact Site Address a City/Town X27 <br /> Owner's Name Phone <br /> Address r« ' City �•- <br /> Contractor's Name i" + License# Business Phone <br /> Contractor's Address & k-s• Emergency Phone p� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�_ No r!"n <br /> TYPE OF WORK (CHECK): NEW WELL❑ ' DEEPEN 13 -RECONDITION❑ DESTRUCTION[:] e v <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ - <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ 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 /> PUMP REPLACEMENT: ❑ State Work Done . - •Q� <br /> PUMP REPAIR: ❑ State Work Doyle _ <br /> DESTRUCTION OF WELL: Well Diameter r, Approximate Depth d <br /> Describe Material and Procedure <br /> I hereby certify that 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which 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 /> 1w/if, call fora rut Inspection prior to grouting and a final inspe n. - <br /> Signed X �` t Title: . .. _ --- Dater <br /> (Draw Plot Plan on Reverse Side) { <br /> p- FOR DEPARTMENT USE ONLY. <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Pha III Final Inspection <br /> Inspection By In Date Inspection B Date <br /> f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 h <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED I <br /> DATE DATE REMITTED AMOUNT <br /> �J a <br /> FEE 6 r Z L <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - a <br /> OTHER a - - <br /> OTHER - - v - <br /> 1 <br /> Received by I Date -- Receipt No.' - Permit No. Issuance Date - Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.D.Box 2009 STOCKTON,CA 95201 <br />