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WWI ns Will Be Processed When'Subltiited Properly CompleteBeSure <br /> EUS z .,.. iPPLICATION <br /> k FOR OFFICE USE: .10 <br /> (� <br /> aT Non-Transterable', Revocable,Suspendable) PUMP&WELL <br /> ffl % 3�`€ ENV,kRQNMENTAL HEALTH PERMIT <br /> HEALTH DIS:TRLCT WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) . <br /> Application is hereby made to the San Joaquin Local Health Districtfor�a permit to construct and/or in the work-herein described.Thisaric <br /> pplicationis <br /> made in compliance w' S a uln C ty Ordli�nan a N 862 and t rules aulations of the S o in o Hr <br /> r `�7� "' City/Town <br /> Exact Site Address C/ V �` ry^� � <br /> ! / /G. Phone' <br /> Owner's Na a �y - l- City <br /> Address ` -37 Busi ss Phone <br /> Contractor's Named License# <br /> Contractor's Address '� r+Emergency'Rhone <br /> No <br /> t Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes ❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK),: W NEW WELL,❑ DEEPEN ❑ RECONDITION <br /> 1 WELL CHLORINATION �J/ WELL ABANDONMENT El OTHER 13 PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank: Sewer Lines y <br /> Sewage Disposal Field <br /> Cesspool/Seepage,Pit - Other R <br /> Property Line Private Domestic Well. Public Domestic Well <br /> 4 TYPE OF WELL <br /> 13INTENDED USE <br /> © NDE L CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> 41 DOMESTIC/PRIVATE <br /> ❑ DOMESTIC/PUBLIC El DRIVEN Gauge of Casing <br /> 11IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION:. Contractor 134 <br /> Type 9f Pump P. <br /> PUMP REPLACEMENT: tate Work Done <br /> PUMP REPAIR: ° State Work Done <br /> Appro ate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: ip <br /> r Describe Material and Procedure . <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> l 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 y any person in such manner as to become sfion <br /> jt to workman's compensation laws of California." <br /> ! Contract iri r sub-conir kn ignature certifies the following:" y that in the performance of the work forwhich this <br /> permit s i u shall pl person subject to workman's comp slaw of California." <br /> I wil ca f r ect' prior rut' g and'a final inspec' n <br /> Signed X ._.Tit1e: <br /> Date: l� <br /> (Draw Plot Plano Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I CLASI Date <br /> Application Accepted By <br /> Additional Comments: rpp se 111 Final Inspection <br /> Phase 11 Grout Inspection ���rI— <br /> Inspection By Date InspectiorY ate <br /> July 1 &Received By July 31 <br /> Fee 1S Due: ❑ ANNUALLY' ❑ PER UNIT ❑ PER SITE «❑ EACH. ❑ January/IIr&/Received By January 31 ❑ <br /> REMIT <br /> BASE EXPLANATION BILLING. REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> k OTHER } <br /> Date °�� Receipt No:'. Permit No: Issuanc Date Mailed Delivered' - <br /> - .Received by 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95291 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - _ <br />