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l. <br /> Applications Will Be Processed When Submitted Properly Completed. BeSureTosign TneRppncanvr �L <br /> (For Nan-Transferable, Revocable,Suspendable) , <br /> . APPLICATION <br /> FOR OFFICE USE: <br /> PUMP&W <br /> ENVIRONMENTAL HEALTH PERMIT <br /> � � <br /> 2' <br /> TER QUALITY , <br /> TER <br /> (COMPLETE IN TRIPLICATE} ,f ] =Ff EY 5 <br /> Application is hereby madetotheSanJoaquinLocalHealthDistrl forapermittoconstructand/orinstallthew11 ork herein described.Thistrio.cation is <br /> j made in compliance it San.Jc quip County. rd'nance No. 1862,an the rules and regulations o;they.S,a oa uin LQcal.HgaltYl District. <br /> Exact Site Address en- <br /> m �� <br /> t <br /> Owner's Nae City <br /> Address Business Phone <br /> Contractor's Name <br /> G - License# � <br /> Q Emergertcy Phone <br /> Contractor's Address No _.t <br /> t' is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes = <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ _ RECONDITION❑ DESTRUCTION❑ <br /> ` WELL CHLORINATION C1 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR rS3 <br /> ` REPLACEMENT❑ es Pit Privy <br /> (V^"� <br /> DISTANCE TO NEAREST: Septic Tank Sewer LCesspooVSeepag <br /> f Sewage_Disposal Field � � e Pit Other <br /> -- <br /> Property Line Private Domestic Well Public Domestic Well <br /> y TYPE OF WELL e 1 <br /> i INTENDED USE } i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation N <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 1. <br /> f ❑ D ESTIC/PUBLIC El DRIVEN Gauge of Casing <br /> RRIGATION - ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: , <br /> PUMP INSTALLATION: Contractor <br /> P. <br /> ,Type of Pum <br /> PUMP REPLACEMENT: 13 State Wor Done <br /> PUMP REPAIR:-----" ❑ State Work Done p� <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> - - Describe Material and Procedure _ -- <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. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> I 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 forwhich this <br /> permit is issued,'l shall employ persons subject to workman's compensation laws of California." <br /> call or a Gro t Inspectio prior t uting and final inspection. <br /> • Title: �""� ' Date: <br /> Signed <br /> 1 (Draw Plot Plan on ReverseSide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I • s ', pate <br /> Application Accepted By <br /> Additional Comments: > <br /> ha e' <br /> nspection <br /> Ph Grout Inspection' <br /> Inspection By <br /> Date Inspection By e <br /> i u <br /> July 1 <br /> Fee Is Due: C3 ANNUALLY - ❑ PER UNiT'I ❑ PER SITE ❑ EACH M ❑ January 1 8 Received By January 31 ❑ 'E,ReceiveJuly 31 <br /> REMIT <br /> BILLING REMITTANCE $ _ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS t s <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER ` <br /> -�Receipt No. — � � Permit No. - �� I uance ate � -. Mailed Delivered <br /> Dale Received by Dat * `� - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95207 <br />