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F Applications Will Be Processed When Submitted Properly Completed.Be SureTo sign Iner;pprrUalul <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> a ENVIRONMENTAL HEALTWPERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work,herein describedh Distrctiication is <br /> made in compliance with San Joaquin County O 'nano a o. 1862 and the ules and re `all City/TownSan loagyila L�c�l <br /> Exact Site Address r <br /> �"`� - Phone ✓ <br /> Owner's Name 1City <br /> Address cj /Esusiness Phone?f f -- <br /> Licenseqp (�1 <br /> Contractor's Name Emergency Phone <br /> Contractor's Address :5 aP [,�—� No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK❑)'. E WELL <br /> A$ANZ;- DEEPEN-0 <br /> p DENT ❑❑ OTHER RO❑ ITION13puMINSTALLATION UCION�pUMP REPAIR❑ <br /> WELL CHLORINATION <br /> REPLACEMENT 171 r <br /> DISTANCE TO NEAREST: Septic Tank © Sewer Lines Pit Privy 17�" <br /> '^ Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL III <br /> ❑ INDUSTRIAL 11CABLE TOOL Dia. of Well Excavation S g <br /> ,,,,,,�� ❑ DRILLED Dia. of Well Casing . <br /> CTpOMESTIC/PRIVATE Gauge of Casing <br /> 11DOMESTIC/PUBLIC ❑ DRIVEN <br /> Pill <br /> ❑ IRRIGATION ❑,, GRAVEL PACK Depth of Grout Seal <br /> [1 CATHODIC PROTECTION M—Ro ARY Type of Grout <br /> ❑ DISPOSAL � 11 OTHER Other Information a- <br /> � Surf�e�l Install By: <br /> ❑ GEOPHYSICAL ' <br /> PUMP INSTALLATION: Contractor'/� <br /> Type of Pump H.P. ae <br /> PUMP REPLACEMENT: ❑ State Work Done 1 <br /> PUMP REPAIR: ' ❑ State Work Done —� <br /> Q DESTRUCTION OF WELL: <br /> Well DiameterApproximate Depth <br /> v 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 /> Home owner or licensed agent's signature certifles the following:"I certify that in the performance of the work for which this permit <br /> 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:'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 /> I willfora rout Inspection prior to groutin a final inspection. <br /> Title: Date: <br /> Signed X <br /> (prow Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PRASE I Date j l y O3 <br /> Application Accepted By <br /> Additional Comments: p e ttl Finai Inspection <br /> ZftasTroul�lnspectlon / bateInspection Byate �r Inspection By <br /> ❑ July 1 8 Received July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 13 January 1 &Received By January 31 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> LESS <br /> PRORATION : _ - <br /> PLUS <br /> PENALTY <br /> f <br /> OTHER <br /> OTHER <br /> No. "� Issuance Date-. Mailed Delivered <br /> Received by Date Receipt No. {1 / <br /> 170 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT! ER ES 1 <br />