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Applications Will Be Processed When Submitted Properly Completed. ae IvnlaV <br /> APPLICATION ,• -,- � ,� / <br /> �lvv V <br /> FOR OFFICE USE: (For Non-Transferable,Revocable,Suspendable) pump QCA�. , <br /> ENVIRONMENTAL-HEALTH PERMIT SAN <br /> H pESTRICT <br /> WATER QUALITY . • t I application is <br /> (COMPLETE IN TRIPLICATE) <br /> ribed <br /> Application is hereby madetotheSan.JoaquikLo�dinancehNo51r862an the rules and egulattiiionsoftthe Sa JoaquinlLocal cHealth TDisthis ct. <br /> made in compliance with San Joaquin Co n y City/Town <br /> Exact Site Address r phone <br /> r , <br /> Owner's Name City <br /> Address License Business Phone <br /> Contractor's Name `l ' t" <br /> Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ` <br /> TYPE OF WDESTRUCTION <br /> ORT( (CHECK): NEW WELL❑ -- DEEPEN❑❑ OTHER RECONDITION1P ❑P INSTALLATION <br /> ❑❑❑ PUMP REPA IR❑J p� <br /> WELL CHLORINATION ❑ WELL ABANDONMI NT <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> Cesspool/seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well ,. <br /> POEOPHYSICAL <br /> ENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> STRIAL ❑ DRILLED Dia. of Well CasingESTIC/PRIVATE Gauge of Casing <br /> ESTIC/PUBLIC ❑ DRIVEN❑ GRAVEL PACK "Depth of Grout Seal <br /> GATION Type of Grout <br /> HODIC PROTECTION ❑ ROTARY❑ OTHEROther Information <br /> OSAL YSurface Seal Installed By: <br /> NSTALLATION: Contractor H.P. <br /> Type of Pump <br /> ❑ State Work Done fit! <br /> PUMP REPLACEMENT: , <br /> PUMP REPAIR: <br /> 11 state Work Done - Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter _ � y - <br /> Describe•Material'And Procedure <br /> t the work will be done in accordance with San Joaquin County <br /> 1 hereby certify that I have prepared this application and tha 'Az <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, l 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 emplqy pers ns subject to workman's compensation laws of California. <br /> I w' II for a out Inspe n pri t routing and a final inspe on.Title: Date. "C <br /> .. <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 C Date ' <br /> Application Accepted By <br /> Additional Comments- Phase III,F.inal-Inspection <br /> se Ii Grout Inspections , ._ _ _ pate !l <br /> Inspection By <br /> Date Inspection By <br /> ❑ PER SITE . 0 EACH ❑ January 1 &Received By J ary 31 13Juiy 1 &Received By July 31' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> OTHER <br /> - .. suanc a tiled were <br /> 15 a Dat M � d Del' d" <br /> -,.,. -Receipt No.— ��' � Permit No. - STOCKTON,CA 95201 <br /> Received.by., - `" --^�"�Da[e�,: - 1601 E.HAZELTON AVE.,P.O.eox 2009 <br /> APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- o- <br />