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Applications Will Be Processed When Submitted Properly Completed. Be Sureiosign IneAppncaawn. ; <br /> FOR OAPPLICATIONFFICE USE: - � <br /> (For Non-Transferable, Revocable,Suspendable) w <br /> A PUMP&WELL <br /> ENVIRONMENTAL HEAL7AWPERMIT p x <br /> YQ ' <br /> f .... ...,. ' k WATER QUALITYVa <br /> (COMPLETE IN TRIPLICATE) �Z, qO'? S .�Z4— dtf <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 /> Ith District. <br /> made in compliance wit San.Joaquin o my rdina ce N 1862 and the r es and r gula' of the San Joaquin Local ale 1 <br /> Exact Site Address <br /> au tyl7bwn ii r/r17� ,!L <br /> Owner's Name <br /> Phone , <br /> _��=/��-����� �'� � <br /> Address r + ' City f,�� i <br /> License#�Z3_ Business P—ho`ne_,� <br /> Contractor's Name h <br /> Contractor's Address l �DEmergency 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 Js� <br /> It Cesspool/see page Pit Other �Sd /'O/17 rOQ }A <br /> Sewage Disposal Field p g <br /> Property tine - Private Domestic Well <br /> Public Domestic Well n <br /> INTENDED USE TYPE OF WELL /i { <br /> ❑ INDUSTRIAL• ❑ CABLE TOOL Dia. of Well Excavation- <br /> DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia- of Well Casing e- <br /> ❑ DOMESTIC/PUBLIC 1c❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout P <br /> ❑ DISPOSAL ❑ OTHER Other Information s , <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> s <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> w <br /> PUMP REPAIR: ❑ State Work Done <br /> i DESTRUCTION OF WELL: Well Diameter Approximate depth <br /> Describe Material and Procedure <br /> 1 I her 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 /> Homeowner 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grou insp I prior to gro ing and fina - eclion. 3 <br /> Signed X It - Date: <br /> (Dr Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY l <br /> PHASE 1 Date /2h) <br /> Application Accepted By x <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection <br /> Inspection By <br /> Datg�P Inspectia By L'� Date i 0 Z <br /> i Fee Is Due: ❑ ANNUALLY ❑ PERU IT ER SITE ❑ January 1 &Received By January 31 July 1 &Recei ed y J 'ly 31 4 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE C ED <br /> • - DATE— DATE REMITTED A NT <br /> FEE ✓t ��/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t OTHER <br /> I scan a Date Mailetl Delivered <br /> Received by -Date "� Receipt No. Permit No, <br /> 1601E.HAZELTONAVE.,P.O.Bo=2009 STOKTON, A 95 1 <br /> APPLICANT--RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES C20 �� <br />