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Applications Will Be Processed When Submitked Properly Complete e u <br /> re <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable; Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY L r x , <br /> (COMPLETE IN TRIPLICATE) the <br /> Application is hereby made to the San Joaquin Local <br /> Health nceNpo.1x862 a dict fO",a pthe rules and egulattiions oftthe Sa work herein Local HeathTDisthis apPhcation+s <br /> made in compliance with an Joaquin County O City/Town ^� <br /> Exact Site Address S� „3• <br /> Phone CQ <br /> Owner's Name <br /> City <br /> Address r License S Bu ' ess Phone <br /> Contractor's Name .• Emergency Phone r <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes }, <br /> TYPE OF WORK {CHECK): NEW WELL❑ EPEN�� OTHERREClTl PUMP INSTALLATION❑DESTRUCTIONO PUMP REPAIR El C^�y11 <br /> WELL.CHLORINATION ❑ WELL ABANDONMENT <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST„ Septic Tank Cessppol/.Seepage-P•it..— --Other. - <br /> Sewage Disposal,F_ield -. ; <br /> Property Line Domestic Well PObiic Domestic Wel! <br /> }Private ,L� <br /> INTENDED USE TYPE OF WELL ¢ � y r <br /> ❑ INDUSTRIAL ❑ _CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED '�.�' D+a. of WelYCasi`ng x_ <br /> ❑ DOMESTIC/PRIVATE '.A lep�o <br /> augeof Gasrng <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN �:❑ GRAVEL PACK �of Grout Seal i I <br /> ❑ IRRIGATION Type of,Grout; <br /> ❑ CATHODIC PROTECTION ❑ ROTARY + <br /> ❑ OTHE `'�+ Other Infvrma}ion <br /> ❑ DISPOSAL _ 3y.' F } <br /> - Surface Seal lnstalled/ <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor k,VV H.P. F <br /> Typefof Pump <br /> PUMP REPLACEMENT: 11State Work-Done 1 <br /> 13 state Work Done <br /> PUMP REPAIR: i i �� ;."a Approximate Depth —' <br /> ' 1 . Well,Diameter j = <br /> DESTRUCTION OF WELL: k l <br /> Describe Material and Procedure V <br /> I hereby certify that I have prepared,this application-and-tf�et-i#�e-vvork w'! 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 certifies the following:"I certify that in the performance of the work forty-of ali 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 mg or sub-contracting signature certifies the following:"1 certify the f the performance of the work forwhich this <br /> permit i + ed, I shall employ p legit to workman's dompensatiol K laws of California." <br /> la �y <br /> I wi for a Grout Ins n prior t rouf and a final inspection. <br /> "� ',, . Date: <br /> i Title: ' ems I <br /> Sig <br /> (Dr'''aw Plot Pfan_gn Reverse Side) <br /> I FOR DEPART fl ENT USE ONLY i <br /> # -S_ga <br /> Date <br /> PHASE 1 , <br /> Application Accepted By <br /> Additional Comments: 3 a I al Inspection <br /> iPh se II Grout Inspection i I e 'on B pate <br /> `- — - <br /> Inspection By * 'Date <br /> I eceived By July 31 <br /> t` ❑ January 1 &Received y <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE' ❑ REMIT <br /> NG REMITTANGE ! AMOUNT DUE CHECKED <br /> BASE '� EXPLAI ATION DATE DATE ;" REMITTED' _ 'AMOUNT <br /> FEE <br /> LESS <br /> �^ PRORATION c_ <br /> PLuS � _ f. ~�• <br /> PENALTY '1 t`•� ,. - 74+- <br /> 1101 <br /> OTHER U�"�"� �!' �' �_ �..•. Y v <br /> OTHER <br /> p Permit No. �, - Iss ante ate Mailed Delivered <br /> Received by W Date Receipt N0. STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEFiMITlSERYICES 1601 E.HAZELTON AVE.,P.O.Bow 2�9 <br />