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ly L;Ornpleleu- <br /> Applications Will Be Processed When Submitted roper <br /> ;FQ,�IFFIce use: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT t. <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> uin Local Health District for a permit to construct and/or install the work.herein described.This application Is <br /> Application is hereby made to the San Joaqe. <br /> made in compliance h San Joaquin Count Ordinance N 862 and t e rules and regulations of the San J quin Local Health District. <br /> City/Town l <br /> Exact Site Address <br /> Phone <br /> Owner's Name P City ��77 <br /> Addressf sBusiness Phone <br /> License <br /> #� <br /> Contractor's Name 1 Emergency Phone <br /> 4 Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 13RECOONNDIT-ION1 r DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENTS RQpU.MP INSTALLATION+�� PUMP REPAIR 4 <br /> I REPLACEMENT❑ Pit Priv <br /> k <br /> DISTANCE TO NEAREST: Septic Tank 10119 Sewer Lines f�T) ' Other <br /> f Sewage Disposal Field Cesspool/Seepage Pit - <br /> ! Property Line 3. Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL + t- .+ <br /> + dia. of-Well,Excavation - <br /> k ❑ INDUSTRIAL'_.'. . , CABLE TOOL ., <br /> j, � ` ❑ DRILLED Dia. of Well Casing , <br /> DOMESTIC/PRIVATE t <br /> ❑ DRIVEN��� Gauge of Casing j <br /> 1 ❑ DOMESTIC/PUBLIC <br /> ❑ IRRIGATION ❑ GRAVIEL€PACK Depth of Grout Seal , <br /> t ❑ ROTARY Type of Grout 2 <br /> ❑ CATHODIC PROTECTION 1 <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL -� Surface,1, - I- stalled By: <br /> +_ t <br /> PUMP INSTALLATION: Contractor } <br /> f Type of Plump i tt z H.P. v <br /> PUMP-REPLACEMENT: <br /> 13 State Work Donk -moi j. I <br /> ` ❑ State Work Done <br /> pUMP:REPAIR: ( l ^pppro�ximate.,Depth <br /> DESTRUCTION OF WELL: Well Diameter �_ I �# <br /> Describe Material and Procedure 1� r <br /> k. <br /> j l hereby certify that I have prepared this application and that the work will"=.bye done i accordance th San Joaquin County <br /> ordinances, stale laws, and rules and reg=ulations 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 for which this permit <br /> k is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> 17 Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance¢of the work for which this E-� <br /> permit is issued, I shall employ persons§ubject to,workman's compensation laws of California." <br /> I will c 11 for a Grout Inspection prior to grouting and a final inspection. I <br /> r ate: <br /> ; - . 1 D <br /> .+ . i L. Title: <br /> I Sign ! X -A---- (15raw Plot Plan on Reverse Side) <br /> { FOR DEPARTMENT USE ONLY <br /> PHASE I C� Date <br /> I Application Accepted By <br /> i <br /> Additional Comments: III Final Inspection <br /> Pha rout ins eci' n f �� fJ ; <br /> p Date r <br /> t Date / Inspection By�V <br /> Inspection By <br /> I Fee Is Due. ❑ 'ANNUALLY' PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31} , <br /> REMIT <br /> REMITTANCE S AMOUNT DUE CHECKED <br /> I EXPLANATION <br /> BILLING REMITTED AMOUNT <br /> BASE DATE DATE <br /> i <br /> FIE <br /> LESS t <br /> PRORATION <br /> E <br /> PLUS <br /> PENALTY <br /> OT¢ER <br /> OT E EIR <br /> issuance Date Mailed Delivered <br /> D e Receipt No._ Permit No.. <br /> Received by - 1601 E.HA2ELTON AYE,P.O.Bax 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES __ - _ <br />