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APqi3tProperlyrr� L , <br /> li tions ill Be Process YVfien Submitted <br /> FOP OFFICE USE: t ��L ���� APPLICATION <br /> (For No Tsierable, Revocable, Suspenrev rR� c.� <br /> PUMP&WEL <br /> '�v p�,i .6VMENTAL HEALTH PERU <br /> WAITER QUALITY <br /> (COMPLETE IN TRIPLICATE) _ i � �� construct and/or 11 the q k Qrein described.This application is <br /> Application ishere bymade tothe an Joaquin Local HealthDisirictforapermittocon <br /> made in compliance with San Joaqui unty Ordina ce No.1 862 and the rules and regy ulati ns of the San Jo�qui Local Health District. <br /> City/Tow <br /> Exact Site Address ��5 <br /> Phone <br /> Owner's Name � City S'raeikTor►/� <br /> Address L'-001 <br /> License# Business Phone ) <br /> Contractor's Name _ Emergency Phone <br /> f Contractor's Address No ( � <br /> i is Certificate of Workman's Compensation Insurance on File With SRErO Yes ✓ V } <br /> TYPE OF WORK (CHECK WE WELL <br /> ABAnDEEPENDONMENT�❑ OTHER ITIO u❑P INSTALLATIOND ❑❑ PUMP REPAIR <br /> WELL CHLORINATION <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> f DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> f Sewage Disposal Field <br /> Property Line Private Domestic Well <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL y <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> INDUSTRIAL Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC [] GRAVEL PACK Depth of_Grout. eal. <br /> ❑ IRRIGATION - <br /> ❑ CATHODIC PROTECTI N� ❑ ROTARY Type of.Grout <br /> ❑ DISPOSAL ❑ OTHER Other Inform ion <br /> Surface Seal I stalled . <br /> ❑ GEOPHYSICAL 4 <br /> PUMP INSTALLATION Contractor <br /> H.P. <br /> Type of Pump <br /> P REP ENT: ❑ State Work Done <br /> r PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter i <br /> I 3: 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 /> Homeowner or licensed agent's signature certifies the following:-I certify.that in the performance of the work to <br /> is <br /> 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." 7 <br /> Contractor's hiring or sub-contracting-signature certifies k the fies the following:"I certify that irperformance of the work forwhich this <br /> I permit is issued, I shall employ persons subject to workman's compensation laws of California:'' ` <br /> k. <br /> r I will call for r Inspection prior-to grouting and a final inspection. <br /> 'Title: r Date: _ <br /> Signed X {Draw Plot Plan on Reverse Side) <br /> <- FOR DEPARTMENT USE ONLY r� <br /> PHASE 1 ice} e 0 Date <br /> f: <br /> Application Accepted By I`1 <br /> Additional Comments: Phase)JFinal pection <br /> 1 Phase II Grout Inspection <br /> Inspection By Date <br /> Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY �E] PER UNIT •❑.PER SITE ❑ EACH ❑ January 5 &Received By January 31 ❑ July 1 &Receiv REMITd By July <br /> 31 <br /> 81LLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE V `^ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> I <br /> OTHER <br /> Receipt No. Permit No. Is ance Dae Mailed Delivered <br /> Received by Date '- 1661 E.HAZELTON AVE.,P.O.Box 2009 -STOCKTON,CA 95201 <br /> 1 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES`^ - <br />