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Applications Will Be Processed When Submittedro ; <br /> APPLICATION <br /> FOR OFFICE USE: Z.. *N (For Non-Transferable, Revocable, Suspendable) PUMP&WEti <br /> E <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> WATER QUALITY <br /> I (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local HealehlD�+st18c�t2 and rules and regulations oftthle San Joaquin l Local HeathTDistrhis riiipplication Is <br /> made in compliance wi(h San Joaquin County ordinance a Q (2 ity/Town <br /> Exact Site Address I <br /> Phone <br /> Owner's Name City r <br /> Address 3_ a 4"1 Business Phone <br /> ,�•_ tense#,�,� <br /> Contractor's Na nergency Phone 9 <br /> Contractor's Addressy No <br /> pt' Is Certificate of Workman's Compensation Insurance on File <br /> ❑With SR CONDITION El DESTRUCTION❑ <br /> f TYPE OF WORK (CHECK): NEW WELL®—DEEPEN <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 'PUMP INSTALLATION C�`PUMP REPAIR❑ <br /> REPLACEMENT❑ it Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank <br /> (� ^�•— Other <br /> Sewage Disposal Fie)d S—.0 '"f Cesspool/Seepage Pit ,tr _ <br /> If <br /> Property LinePrivate Domestic Well — <br /> Public Domestic Well <br /> f TYPE OF WELL <br /> 1 INTENDED USE Dia. o <br /> 11 CABLE TOOL f Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> M x� <br /> ❑OMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC Depth of Grout Seal ~0 <br /> I ❑ IRRIGATION ❑ GRAVEL PACK �`- <br /> �ARY Type of Grout <br /> 11 CATHODIC PROTECTION Other Information <br /> 11 DISPOSAL ❑ OTHER . S M ti <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor < H P <br /> Type of Pump <br /> I PUMP REPLACEMENT: <br /> ❑ State Work Dome <br /> ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> I Describe Material and Procedure <br /> I hat the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this application and t <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, 1 <br /> Home owner or licensed agent's signature certifies 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 /> erformance of the work forwhich this <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the p <br /> permit is issued, I shall employ ersons subject to workman's compensation laws of California." <br /> 11 call for a Grout t n rio to grouting and a final inspection. t y <br /> f Bate: <br /> Title: <br /> ttiV� <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY i <br /> I PHASE I <br /> Date <br /> Application Accepted By <br /> 1. Additional Comments: <br /> as spection <br /> Phase II Grout Inspection 1 pate <br /> k a Inspection By <br /> Inspection By _ - <br /> � d <br /> Fee Is Due: C3 ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMIT Received 31 <br /> i BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE f DATEREMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> OTHER <br /> Issuance Date Mailed De4ivered <br /> at Receipt No. Permit No. <br /> LL; <br /> _ Received by -1601 E.HAZELTON AVE.,P.O.Box 2509 _STOCKTON,CA 45201 <br /> ' w APPLICANT=RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - -, _ <br />