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Ad Applications Will-Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> CE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONM NTAL HEALTH PERMIT <br /> � IPLETE IN TRIPLICATE) Z,��2 J � UALIT� <br /> .�pplicationishereby made toth nJoaquinLocal Health Districfor aperm onstructNnd/or install the work herein described.This application is <br /> / made in compliance with Joaqui ounty Ordinance No. 186 and t e rules apd regulati s of the n Joaquin Local alth Distrix. <br /> Exact Site Address'. {� <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Na Ae�sF4 Te. 0 FS1 Business Phone �-C/ 1s <br /> Contractor's Address rgency Phone <br /> Is Certificate of Workman's Compensation Insura ce on File With SJLHD? Yes �` No <br /> TYPE OF WORK (CHECK): NEW WELL�DEEPEN ❑ RECONDITION E] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER El # PUMP INSTALLATION ❑ PUMP REPAIR❑ ', <br /> REPLACEMENT❑ l <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 4— Cesspool/S7epage Pith,Other <br /> t <br /> Property Line Private Domestic Well� Public Domestic Well <br /> INTENDED USE TYPE OF WELL ` <br /> ❑ INDUSTRIAL �" ❑ CABLE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE " ❑ DRILLED Dia. of Well Casing `I <br /> ❑ <br /> �. x❑ DRIVEN Gauge of Casing <br /> l DOMESTIC/PUBLIC'. 9 9 6' <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> -;^ �— <br /> ❑ CATHODIC PROTECTION% RY _ Type of Grout fn <br /> ❑ DISPOSAL ❑ OTHER. Other Information V' <br /> ❑ GEOPHYSICAL ti <br /> 1 Surface Seal Installed B R/"G� <br /> PUMP INSTALLATION: , a1%Contr <br /> 4 <br /> "'Type of Pump ---_ H.P. <br /> PUMP REPLACEMENT; �Xr y .❑ State-Wo-Fk•DoRe�-- <br /> PUMP REPAIR: F ,A ❑ State Work Done .� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> e 4 <br /> I hereby certify that l 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-co ting signature certifies the following:"1 certify that in the performance of the work forwhich this <br /> permit is issued, I shall e I y pe ons subject to workman's compensation laws of California." <br /> will call for a Gro sp ti prio uting and a final inspection. °`N ' a <br /> 1` <br /> Si Title: Date: <br /> (Draw Plat Plan on Reverse'Side) s . <br /> FOR DEPARTMENT USE ONLY <br /> PH } Q r <br /> Application Accepted By f. Date <br /> Additional Comments:- <br /> Ph,ase 11 Grout Inspection 1 P se II Final Inspection <br /> Inspection By Date % "7 1k 'Inspection By } Date <br /> 1. <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE #" <br /> LESS <br /> PRORATION 1 <br /> PLUS j 1. <br /> PENALTY i <br /> OTHER k <br /> OTHER f j <br /> l C7 <br /> �eceived by qate r 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 />