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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> 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 San Joaquin unty Ordinance N 186 and the rules and regulations of the San J uin Lgcal ealth District. <br /> Exact Site Address tr City/Town <br /> Owner's Name -e /- '261 r t Phone �r 7` <br /> Address 7 <br /> 7 <br /> �5zCCity <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> 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 f 4 <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Wel Excabtic� <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of'Ad Casing �,!! `t <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN GaA df Casi <br /> E] IRRIGATION ❑ GRAVELPAC Depth ofrrout Seal <br /> ❑ CATHODIC PROTECTION © ROTARY e of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Infor' do <br /> ❑ GEOPHYSICAL ' Surface Seal In <br /> PUMP INSTALLATION: Contracto'- , <br /> Type of Pump ASP <br /> PUMP REPLACEMENT: ❑ State Work Done rFr <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter App ximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that Lhave 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 call for a,Grout Inspection prior to grouting and a final inspection. <br /> 9 <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 /> Additional Comments: 5 , <br /> Phase,ll Grout Inspection Phase III Final Inspection <br /> Inspection By H Date " " Inspection By Date <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &fieceived By July 31 <br /> Fee IS Due: 13 ANNUALLY ❑ PER UNIT• <br /> REMIT <br /> BAS&, EXPLANATIONBILLING REMITTANCE-,. $ n _ "AMOUNT DUE- CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> ;..i . <br /> ' FEE p� <br /> I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k <br /> Received 5y Date Receipt No. Permit No. Issuance Date Mailed Delivered .. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />