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Applications Will Be Processed When Submitted Property Completed BeSureTosign IneRppan:a11v11. <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL l <br /> ENVIRONMENTAL HEALTH PERMIT W <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 an the rules a d11 /regulations of the San Joa uin Lo' al Health District. <br /> Exact Site Addressfly L o.�; hr,of City/Town <br /> Phone <br /> Owner's Name <br /> Address J4 City <br /> Contractor's Name <br /> icense#S Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes�� <br /> No �} <br /> TYPE OF WORK (CHECK): NEW WELL& DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ f f <br /> DISTANCE TO NEAREST: Septic Tank 7 �' Sewer Lines O Pit Privy F <br /> ! Cesspool/Seepage Pit Other GI <br /> Sewage Disposal Fuld - <br /> Property Line/a_.�Ik_Private Domestic Welles public Domestic Well <br /> INTENDED USE f TYPE OF WELL <br /> INDUSTRIAL <br /> 11 CABLE TOOL Dia. of Well Excavation <br /> • ❑ it <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ElDRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 5 (� <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> ❑ <br /> PUMP REPLACEMENT: State Work Done � <br /> PUMP REPAIR: ❑ State Work Done <br /> I ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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. <br /> I Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> ris issued, I'shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> f Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this j <br /> s ject to workman's compensation laws of California." <br /> permit is issued,`I shall employ persons <br /> I wi I for a Grou sp n pr r grouting and a final inspection. <br /> r. Title: <br /> ' Dater <br /> Signed X <br /> (Draw Plot Plan on Reverse Sid <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I pate <br /> Application Accepted By <br /> Additional Comments: - _ + <br /> I <br /> ?Phse II out inspection Kase III Final Inspection <br /> Date In'sp tion By Date <br /> Inspection By <br /> x eceived By July 31 <br /> �- Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By anu -%,REWT <br /> BASE EXPLANATION' BILLING REMITTANCE $ AMOUNT DUE CiIECKED <br /> DATE DATE REMITTED AMOUNT <br /> f <br /> FEE <br /> LESS <br /> PRORATION <br /> PWS <br /> PENALTY tt <br /> OTHER <br /> is <br /> OTHER « <br /> vered <br /> Date Receipt No.- Permit No. issuance Date ,Mailetl Deli <br /> Received by - <br /> i <br /> 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES•TOf 4,-ENVIRONMENTAL HEALTH PERMIT/SERVICES ' <br />