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-- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION J <br /> ble, Rer <br /> (For Nan-Transferable, Suspendable) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT s <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct an, <br /> install the work herein described.This application Is <br /> made in compliance with San Joaqul kounty rdinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone'' <br /> Owner's Name � . PA � �� <br /> n Y City <br /> Address AKA W` <br /> License# Business Phone <br /> Contractor's Name <br /> k " <br /> Contractor's Address Emergency Phone No <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? . Yeses l <br /> TYPE OF WORK (CHECK): NEW WELL ❑❑ OTHER ITIOPU❑MP INSTALLATION DESTRUCO❑ PUMP REPAIR® f <br /> NO <br /> WELL CHLORINATION ❑ WELL ABANDONMENT S <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank: Sewer Lines Y <br /> Sewage Disposal Field - <br /> °Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ( ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ' ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> "0 DOMESTIC/PUBLIC u ❑ DRIVEN Gauge of Casing <br /> 0 IRRIGATION ❑ GRAVEL PACK 41 Depth of Grout Seal <br /> t ❑ CATHODIC PROTECTION ❑ ROTARY ' Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surfa�cerSgsal Installed By: <br /> Contractor <br /> PUMP INSTALLATION: �J <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done - <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i t - <br /> r 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. ,l <br /> Home owner or licensed agent's signature certifies the tollowing:"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:"I certify that in the performance of the work forwhich this <br /> f permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> IW.i call for a Grout Inspection t, �rouiil{" <br /> and az incl inspection. <br /> fitle: _ Date:. <br /> Signed <br /> 6� (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � Date <br /> Application Accepted By <br /> Additional Comments: t <br /> Phase 11 Grout Inspection ase III Final In ection <br /> 1v� 1 n� - � 1 to <br /> Inspection 13y ' " Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER LI ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ' ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED' <br /> -- - BASE EXPLANATION DATE DATE REMITTED, AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - - - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - <br /> -Date �Receipt-No, - Permit No. - ssuan Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: <br /> 1601 E-HAZELTON AVE.,P.O.box 2009 STOCKTON,CA 95201 <br /> ENVIRONMENTAL HEALTH PEAMITISEAVICES <br />