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r--.. . <br /> n <br /> . Applf i ns Will BeProcessed Whe mitted roper y opn APPLICATIONSE: MAY11 i L M <br /> ( or on-Transferable, Revocable,Suspendable) PUMP&WELL <br /> SAN JOAQUIN�NMENTAL HEALTH PERMIT <br /> { HEALTH DISTRICT WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 n Jo L ount Or nce No. 186 an the rules d re lotions of the San Jo uin Local Health District. <br /> 60&,ekl V rN City/Town <br /> Exact Site Address r I �' n rT-^y- . 1s <br /> f ! Phone <br /> Owner's Nam � City ZO <br /> AddressBusiness Phone <br /> icense <br /> Contractor's Name Emergency Phone Q � <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Ins rance on File With SJLHD? Yes l <br /> TYPE OF WORK (CHECK WE W qB- ONMENT ❑DEEPEN ❑ OTHERO❑ ITI PUMP INSDTALLA7 ON� PUMP REPAIR <br /> WELL CHLORINATION <br /> REPLACEMENT❑ ( f <br /> 6 Sewer Lines ` Pit Privy <br /> DISTANCE TO NEAREST: Septic Tankyy 1 Cesspool/Seepage Pit Other <br /> Sewage Disposal Fiell� _ t1� <br /> Property Line Private Domestic We1I I.t2U Public Domestic Well <br /> INTENDED USE TYPE OF WELL 2— 'n G <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> r ❑ DOMESTIC/PRIVATE DRILLED <br /> Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing 0 <br /> € <br /> IRRIGATION13 GRAVEL PACK Depth of Grout Seal <br /> - <br /> ❑ CATHODIC PROTECTION <br /> 11 ROTARY Type of Grout <br /> ❑ DISPOSAL El OTHER Other Information <br /> surface Sealtailed By: <br /> 11 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 11 State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> E DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> [ I hereby certify that I havelprepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and .ides and regulations of the San Joaquin Local Health District. <br /> I <br /> Homeowner or licensed agent's signature certifies the following:"1 certify that in the performance ofthe 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 /> j Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I it 11 for a Gr Inspection prior to grouting and a final inspection. <br /> "`Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse lde} <br /> /j FO <br /> DE MENT E ONLY <br /> f PHASE I // //�„� a� <br /> .dam Date <br /> Application Accepted By <br /> Additional Comments: Phase IH Final inspection �} <br /> Phase ll Grout Inspection Date <br /> Inspection By p <br /> I Date Inspection By 4 <br /> • <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> C] January 1 &Received By January 31 /C] July 1 &ReceivedJuly 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i BASE EXPLANATION DAT HATE REMITTED AMOUNT <br /> i <br /> FEE <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER i <br /> t 4 -Y <br /> i Receipt No. Permit No. Issu nce Date Mailed Delivered <br /> Received by Date . <br /> 1601 E.-HAZELTON AVE.,P.O.60■2009 STOCKTON,CA 9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />