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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> R � <br /> FOR OFFICE USE:z: _ APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> + PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> x (COMPLETE IN TRIPLICATE) WATER QUALITY <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 Gount Ordinance No. 186 an the s and regulations of the San Joaquin Local Health District. <br /> { Exact Site Address City/Town - r.—e <br /> Owner's NamePhone <br /> _._ -' <br /> i Address r <br /> city � �'--c o <br /> t Contractor's Name` License# Business,Bhone <br /> I Contractor's Address Emergency Phone <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ` No O <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRA <br /> REPLACEMENT❑ - <br /> I 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 J <br /> ❑ GEOPHYSICAL Surface Seal Installed By: _J <br /> PUMP INSTALLATION: Contractor <br /> ' Type of Pump H.P. .{ <br /> PUMP REPLACEMENT: State Work Done . n <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter lApproxim�Pll,�'pth <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 /> 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, 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I_will call for 4,G rout Inspection rior to grouting and a final inspe n. <br /> Signed X Title:- Date: � � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> i <br /> Additional Comments: <br /> Phase II Grout Inspection Phase II Fin g speclion <br /> Inspection By Date Inspection By Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31' <br /> BILLING REMITTANCE REMIT <br /> BASE EXP $LANATION AMOUNT DUECHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS i <br /> PRORATION <br /> PLUS F <br /> PENALTY <br /> OTHER <br /> OTHER <br /> to 0 <br /> Received by ""Date Receipt No. Permit No. - Issuance Date a Mailed D ivered - a <br /> `. APPLICANT—RETURN ALL COPIES.TO:.. ENVIRONMENTAL HEALTH PERMINSERYICEs " - —�y 1601 to HAZE AVE.-.P.O.BOY 2009 STOCKTON,CA 95201 1 <br />