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Applications Will Be Processed When Submitted Properly <br /> FO. OFFICE USE: (For Non-Transferable, Revocable,Suspendable) PUMP&WCL( <br /> Ca►+� . <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) o' construct <br /> i Application is hereby made to the San Joaquin Local Health District for <br /> a dpermit rules and egulations oftthe San Joaqurnl Lo31scr <br /> Healdth Dist.This rict, Is <br /> made in compliance with-San Joaqui Count O,rdina ce�Y City/Town <br /> i Exact Site Address <br /> Phone <br /> Owner's Name 8"OV�" Q City0110 <br /> d11" <br /> Address License# /� Business Phone I �s � <br /> Contractor's Nam Emergency Phone <br /> xJLHD? Yes No <br /> Contractor's Address <br /> Is Certificate of Workman's Co ripen anon n❑surancDe onPFN❑ th SR CONDITION STRUCTION❑ <br /> r TYPE OF WORK (CHECK)'. r <br /> WELL CHLORINATION ❑ -WELL ABANDONMENT 0 OTHER P ' PUMP IN <br /> ❑ PUMP REPAIR <br /> REPLACEMENT❑ Sewer Lines- Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank .� F Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> ` INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> 29 INDUSTRIAL Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE 13 DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout <br /> f ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ OTHER- Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor <br /> PUMP INSTALLATION: �� H.P. <br /> Type of Pump <br /> ❑ State Work Done °" r aj� <br /> PUMP REPLACEMENT: ® State Work Done -� a� <br /> t PUMP REPAIR: <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> ordance withSan Joaquin County <br /> I hereby certify that I have prepared this application and that the work will be done in acc � <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's. cerrtifies.t_he�owing:"I certify that in tfie performance of thework for which this permit <br /> H issued, l shall l not employ any person in such mnner,as to become subject to workman's compensation laws of California.;, <br /> Contractor's hiring or sub-contracting signature certifies the following:'9 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 /> a ti al inspection. <br /> 1 wi call for a Grout Inspectio pr to ro ng Date: <br /> Signed X (Dr{aw Plot P1 n Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date <br /> E Application Accepted By <br /> Additional Comments: has 111 Final inspection �,. <br /> q Phase 11 Grout Inspection y c Date r1 <br /> Date Inspection By _ <br /> ( Inspection By <br /> PER UN4T ❑ ❑ EACH ❑ January 1-&Received By January 31 ❑ July &Received By July 31 <br /> Fee 1S Due: 13 ANNUALLY PER SITE❑ REMIT - <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> I PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Permil No ssua ce D to Mailed Delivered <br /> Received by - Date Receipt No. [�,�/!71 <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HA2ELTON AVE.,P.O.Box 2009 ' �STOCKTON,CAB�¢U <br />