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perty <br /> Applications Will Be Processed When SuAPPLICATION <br /> FOR-c CE USE: (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WAYER QUALITY application Is <br /> ocal Health,District. ' <br /> (COMPLETE IN TRIPLICATE) n Joa uin Local Health District for a permitta construct an do°s of <br /> Sin Joa ework herein described.This <br /> Application is hereby madetotheSa q / <br /> made in comp <br /> Bance with San Joaquin County Ordinance N . i862 a the rules nd r <br /> Exact Siie Address Phone , <br /> City <br /> Owner's Name <br /> Address —F, III <br /> Lice1nss # Business Phone <br /> Contractor's Name /Ex ergency Phone <br /> No —� <br /> Contractor's Address <br /> Compensation Insurance on File With SJLHD? Yes ❑ pESTRUCTION� <br /> is Certificate of Workman's Co NEW WELL DEEPEN❑ RECONDITION 1 <br /> TYPE OF WORK (CHECK) 1J <br /> CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION� PUMP REPA1 <br /> WELL CHL -4 Pit Privy <br /> REPLACEMENT❑ r Sewpr LLines'----- Other <br /> DISTANCE TO NEAREST: Septic Tank / * Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well li <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Wei; Excavation I� �(, <br /> I ❑ 1 DUSTRIAL 11A LLED Dia. of Well Casing a <br /> f [IpOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC RAVEL PACK Depth of Grout Seal <br /> I ❑ IRRIGATION VROTARY Type of Grout 1 <br /> ❑ CATHODIC PROTECTION tII'� Other Information <br /> ❑ OTHER ------ <br /> j" <br /> i El DISPOSAL Surface Seal installed By: <br /> 4 ❑ GEOPHYSICAL Contractor H.P. <br /> M PUMP INSTALLATION: <br /> Type of Pump <br /> ❑ State Work Done <br /> k PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter. <br /> Describe Material and Procedure <br /> i, <br /> r <br /> I hereby certify that I have prepared this ccordance with San Joaquin County <br /> application and that the work will be done in a <br /> I certify that in the performance of the work for which this permit <br /> h ordinances, state flaws, and rules and regulations of the San Joaquin Local Health District, <br /> I F•" Home owner or licensed agent's signature certifies the following:` _ Y <br /> issued, I shall not employ any person in such manner as to"become subject to workman's compensation laws t California. <br /> is g. Y <br /> ' <br /> Contractor orsub-contracting signature to twol•kman's�lcompensati°nf laws tof Caliin the PornDamance of the work forwhich this <br /> t I shall employ persons subject <br /> permit is issued, ion. <br /> I wil call for a Grout'ns on prior t 'grouting and a f' all in Date: <br /> Titl -f <br /> Signed X ( raw Plot Plan verse Side <br /> t FOR DEPARTMENT USE ONLY 7fp,I <br /> F7—, Y � r Da�te <br /> PHASv <br /> � <br /> ' <br /> Application Accepted By <br /> Additional Comments: <br /> �` Phase III Final Inspection <br /> � <br /> Phase II Grout inspection Inspection By Date <br /> Inspection By D ate January 31 July 1 &Received 8y July 31 <br /> k REMIT <br /> 4 Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE C1 EACH ❑ January t &Received By AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE ` <br /> j LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> f r,. <br /> OTHER <br /> OTHER rn _ .. <br /> ry U VMailed Delivered <br /> U Permit No. Iss ance ate GA•95201 <br /> Date Receipt No. 1601 E.„AZELTON AVE.,P.O.Box 2009 STOCKTON, <br /> _ yRec ived by ENVIRONMENTAL HEALTH.PERMITISERVICES <br /> "; <br /> APPLICANT=RETURN ALL COPIES TO: , <br />