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Applications Will Be Processed When Sub�mPPLICAProperly <br /> TIONpFezeo- oeaurc 1 -.y I, <br /> !1FFICE JSE: t` l <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ` <br /> WATER QUALITY <br /> (COMPLETE iN TRIPLICATE) <br /> Application is herebymadetotheSanJoaquinLocaIHealthDistrictforapermittoconstructand/or install the work herein described.This application Is <br /> made in compliance with San Joaquin Cou ty O 'nance No. 186 d he ru es nd regulations City/Town Joaquin Local Health District. <br /> If V,, <br /> Exact Site Address <br /> i Phone .. � (jet. <br /> Owner's Name s , Phone <br /> F AddressLicense Business Phone Z <br /> � �-- � <br /> f Contractor's Name 1 Emergency Phone <br /> L. 3 ' - <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insu nee on File With SJLHD? Yes �� 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER 11 PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ -Pit Priv <br /> Sewer Lines /Q� y <br /> DISTANCE TO NEAREST: Septic Tankn Cesspool/Seepage Pit ��� Other <br /> Sewage Disposal Field _ <br /> Private Domestic Well <br /> Public Domestic Well <br /> Property Line- _ <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> DOMESTIC/PUBLIC LJ DRIVEN �J <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> l ❑ CATHODIC PROTECTION '%ROTARY <br /> Type of Grout <br /> EI DISPOSAL L� OTHER Other Information <br /> Su face SiIns lled By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor1:1!11111 . <br /> Type of Pump H.P. <br /> f -� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done - <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> r <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. r <br /> i <br /> Home owner or licensed agent's signature certifies the following:"l certify that in the performance of the work for which this perms <br /> t to become subject to workman's compensation laws of California." <br /> is issued, I shall not employ any person in such manner as <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> fpermit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi all for a out Inspection prior to grouting and a final inspection• d <br /> i Title: Side) <br /> Date: <br /> Signed <br /> (Draw Plot Plan on Rever ) <br /> f III FOR DEPARTMENT USE ONLY <br /> PHASE I I! 11\f. 1� Date <br /> C Application Accepted 8y <br /> Additional Comments:�� a itl Fi 1 inspection <br /> I: hase It Grout Ipspection , <br /> ell% °�`� Date� /3i� Inspection By Date <br /> Inspection 8y � - "` <br /> ow'f`^l3eN� i-1-81 c-e,eucr�c/c;,r�.�f <br /> t s' � ` 9� — <br /> ee Is Due: ❑ ANNUALLY J3 PER UNVT ❑ PER SITE EACH ❑ January 1 &Received By January 31 El 1 �Received 37 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> kASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> i FEE <br /> E LESS I`I <br /> PRORATION iP <br /> PLUSPENALTYlJt�i- U) "i ��Z//� U 7G1 TC / <br /> let- <br /> OTHER OTHER <br /> OTHER <br /> a <br /> ��. I uance to Mailed Delivered <br /> ' Date _ Receipt No. Permit No. <br /> Received by ,�- :I�: 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA.95201 <br /> APPLICANT—RETURN A`L COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br /> - <br />