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Applications Will Be Processed When Submitte Properly , <br /> FOR OFFICE USE: <br /> APPLICATION <br /> { (For Non-Transferable,Revocable,Suspendable) pUMP&WEA„ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqui ounty Ordi ce No. 1862 an a rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address *+�k? <br /> r. j l q �1 Phone <br /> Owners Name - <br /> AddressC City <br /> Contractors Name <br /> License#��I,1_ Business Phone <br /> Contractor's Address Emergency Phone — i <br /> No <br /> Is Certificate of Workman's Compensation Insu I ce on Fil ith SJLHD? Yes _ <br /> ,TYPE OF WORK (CHECK): NEW WELL DEEPEN' RECONDITION DESTRUCTION❑ <br /> ❑ <br /> WELL CHLORINATION ❑ WELL ABANDON NT ❑ OTHER ❑ PU I <br /> P INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> - <br /> DISTANCE TO NEAREST: Septic Tank -Sewer-Lines" Y - Pit Privy.- - <br /> Sewage Disposal Field Cesspool/Seepage Pit Other _A <br /> Property Line Private Domestic Wel! <br /> Public Domestic Well <br /> INTENDED USE T E OF WELL <br /> ❑ IN TRIAL 113-CABLE TOOL Dia. of Well Excavation—ra <br /> UYDOMESTIC/PRIVATEIFI <br /> ❑ DRILLED Dia. of Well Casing <br /> I ❑ DOMESTIC/PUBLIC <br /> 11 DRIVEN Gauge of Casing <br /> 11GRAVEL PACK Depth of Grout Seal r <br /> ❑ IRRIGATION '• <br /> 0-CATHODIC PROTECTION ❑ ROTARY Type of Grout _ -- n <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL a.-�` Surface Seal Installed By: <br /> s` --� <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑_State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> - Approximate Depth <br /> Describe Material and Procedure z <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 for which this permit ti <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 /> permit is issued, I shall employ per ons subject to workman's compensation laws of California." } <br /> t I will caft7or a Grout Inspect i sort grouting and a final inspeIII I0c <br /> Signed X Title: Date: <br /> f (Draw of Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY 7..- <br /> �Da <br /> PHASEIApplication Accepted By <br /> Additional Comments: h II Grout Inspection P e ll final InspectioInspection By <br /> at Inspectio Byr�� .Y <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 eceived-By-January 3l ❑ July 1 8 ReceiveRdEBn�gIT 31 <br /> 1. <br /> BASE EXPLANATION BILLING REMITTANC J $ AMOUNT DUE CHECKED F <br /> DATE DATE REMITTED _ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS etAtl1b - r <br /> PENALTY <br /> OTHER <br /> r OTHER - <br /> �3 <br /> n <br /> I uanc Date Mailed Delivered <br /> Received by Date Receipt No ,� x Permit No. — <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM 1601 E.HAZELTON AVE.,P.O.Boa 2409 STOCKTON,CA95201 / <br /> r �r+� <br />