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App dations Will Be Processed Wheh 9 mitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: U_�lS JUL — re IS82 APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> SA(-4 `fO Q1,J13�J EI'V1.RPNMENTAL HEALTH PERMIT <br /> HEALTH DISTRICT WATER QUALITY � <br /> (COMPLETE IN TRIPLICATE} 4, Cr)wl I,•A <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is y <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. r, <br /> Exact Site Address 915 R City/Town <br /> Stockton <br /> Phone 478--6882 <br /> Owner's Name - <br /> Address rr > ,. City . ' ° • n .. <br /> Contractor's Name License# 267696- . Business Phone_ <br /> Contractor's Address 2120 Wil.+a - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ . <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONXI PUMP REPAIR❑ fl J <br /> REPLACEMENTS r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other V <br /> 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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL El OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor tMg <br /> Type of Pump - H.P. I <br /> PUMP REPLACEMENT- x❑ State Work Done r ace f�xistin um with new1 HP <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ii <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 <br /> ordinances, state laws, and rules and regulations 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 /> Jr <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 fallowing:"I certify that in the performance of the work for which this r <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> I will call fora Grout Inspection prior to grouting and a final inspection. <br /> Signed X - Ti11e: !� Date: — <br /> ` (Draw Plot Plan on Reverse Side) -i _.y. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted Byy - Date <br /> Additional Comments: <br /> Phase I! Grout Inspection hose 111 Fi I Inspection , <br /> Inspection By Date Inspection By Date `?I <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE_. "EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED. AMOUNT <br /> FEE s LIS <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> OTHER <br /> Received by Date -Receipt No. Permit No. Is trance D to Mailed' Delivered - <br /> L <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />