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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> l .(5FPfC= <br /> USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> # <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thew ork herein described.This application is <br /> made in compliance with Sedan Joaquin County Ordin nC N 8662 and he ruI;Vnd regulations of the San Joaquin Local Health District. <br /> 11 <br /> Exact Site Address,S ! I57 � ,� /l' City/Town <br /> / <br /> Owner's Name Phone <br /> Address /� City <br /> Contractor's Name 4 License Business Phone .2 <br /> .,Contractor's Address _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No i <br /> TYPE OF WORK (CHECK): NEW WELL m---DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ } <br /> REPLACEMENT❑ / B ` <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy j <br /> Sewage Disposal Field lOwl ` Cesspool/Seepage Pit Other <br /> Property Line .IA7 Private Domestic Wel! Public Domestic Well <br /> 1 <br /> INTENDED USE TYPE OF WELL <br /> 1 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ©'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing rr <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> W <br /> 13 IRRIGATION 11,ts��,��GR��AVEL PACK Depth of Grout Seal <br /> -1 CATHODIC PROTECTION 'ROTARY Type of Grout 1 <br /> ❑ DISPOSAL ❑ OTHER Other Information (A <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P.• <br /> PUMP REPLACEMENT: ❑ State Work Done i <br /> PUMP REPAIR: ❑ State Work Done <br /> I DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> E <br /> 1 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will 1 for a Grout Inspection prior to ro ing and a final inspection. <br /> Signed X Title: Date: 8 <br /> f (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By � Date d <br /> Additional Comments: <br /> P Grout I ection Q P ase NI Fi Inspection <br /> Inspection By ate Inspection Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received Ry July 31 <br /> REMIT <br /> BASE' EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE cJ I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0 0 1�' <br /> Received by Date Receipt No. Permit No, Issuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 76p1 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />