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PIMiongWill BeProcessed When Submitted Properly Completed. Be Sure a Application. <br /> Sign The <br /> FOR OFFICE USE: �gSO APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> (COMPLETE IN TRIPLICATE) 5A� 0}-j~DNE kV11"MENTAL HEALTH PERMIT PUMP&WELL i <br /> 14F A WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 186 ` nd the rules and regulations of the San Joaquin Local ea th Districts <br /> Exact Site Address �.5��v Ir�J <br /> ( City/Town / 0 �,� <br /> Owner's Name � � � <br /> Address Phone <br /> Contractor's Name �} City .s1 <br /> License#�� Business Phone ��,�r} 7 <br /> Contractor's Address � <br /> Emergency Phone �— <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK); NEW WELL ElDEEPEN ❑ RECONDITION ElDESTRUCTION❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTI� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Linesf <br /> Pit Privy <br /> Sewage Disposal'Field Cesspool/Seepage Pit, r. <br /> OtherPro <br /> Property Line Private domestic <br /> Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> I6 DOMESTIC/PRIVATE 0 Dia. of Well Excavation ) <br /> 11DOMESTIC/PUBLIC :DRILLED Dia, of Well Casing <br /> DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ❑ ROTARYI <br /> 11 DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br /> PUMP REPLACEMENT: 21 State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL; <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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. �1 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit J <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 w! II for-al Grou Hsps on pri-r to grouting and a final inspects <br /> (brow Plot <br /> Signed X — 3 <br /> TTitle-�. - .. _._...t. Date: _ ( i <br /> ( Plan on Reverse Side) <br /> PHASEI <br /> FOR DEPARTMENT USE ONLY <br /> — <br /> Application Accepted By 047 <br /> Additional Comments: Date 6V <br /> Phase II Grout Inspection <br /> Phase III Final Inspection <br /> Inspection By Date Inspection By <br /> Date , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED ' <br /> FEE AMOUNT <br /> LESS a 4H S <br /> PRORATION Ua(k ed irGf✓�(� {N <br /> PLUS <br /> PENALTY e, j- <br /> r { <br /> OTHER <br /> I ✓j <br /> OTHER , . + <br /> Received by Date - Receipt No. Permit No. ' <br /> APPLICANT=RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES .. Issuance Date Mailed pelivered <br /> f 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOCKTON,CA 95201 <br />