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Applications,Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOP,OFFICE USE: APPLICATION R <br /> ,I (For Non-Transferable,--Revoce"ble,Suspendable) PUMP&WELL <br /> _ II� ENVIRONMENTAL HEALTH PERMIT <br /> it <br /> (C0;IAPLETE IN TRIPLICATE) WATER QUALITY <br /> ill t'. .; - - r, a c, -r , e+:t -, � <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapytionis <br /> erm it to construct and/or install the work hereindescribed.This applica <br /> made in compliance with San Joa uin County Ordinance NO.1862 and th "rules and requlatlo f the'San Joaquin Local Health District. <br /> (�, 44 �fTown Ly <br /> Exact Site Address <br /> r .gin. Phohe� <br /> Owner's Name � � t y <br /> Address r .- City._. 722 _ #,I <br /> Contractor's Name License# j - Business Phone .r=���✓` "�f� O <br /> t <br /> Contractor's Address 2� Emergency.Phone.. c ` -° r - " <br /> Is Certificate of Workman's Comperlsation Insurance on File With SJLHD? Yes X No 5 <br /> TYPE OF WORk (CHECK):" NEW WELL—:7;bEEPEN'❑-"'---RECONDITION❑— DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> K <br /> REPLACEMENT❑ " <br /> DISTANCE TO NEAREST: Septic Tank �� Sewer Lines'. Pik Privy <br /> fi <br /> Sewage Disposal Field / _ Cesspool/Seepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> 1 <br /> i INTENDED USE i TYPE OF.WELL N <br /> :I <br /> ❑ INDUSTRIAL I! ❑ CABLE TOOL Dia. of Well Excavation <br /> 19 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑DOMESTIC/PUBLIC b.. ❑ DRIVEN Gauge of Casing <br /> 1cxr <br /> El IRRIGATION J,vaf GRAVEL PACK Depth of Grout Seal <br /> El PROTECTION X>r ROTARY Type of Grout r, <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> t ❑ GEOPHYSICAL N .. Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor - <br /> !! Type of Pump -KP. <br /> PUMP REPLACEMENT: 11 ❑ State Work Done <br /> PUMP REPAIR: Tili ❑ State Work Done <br /> DESTRUCTION OF WELL: ��I Well Diameter Approximate Depth <br /> f I' Describe Material and Procedure <br /> k 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 /> Home owner or licensed agent's'signature certifies the following:"i certify that in the performance ofthe 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:"l certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California,"' <br /> I twill all for a Grout InspSoyon prior to grouting and a final inspection. <br /> Signed X <br /> I. Title: Date: a?� <br /> � _ - - <br /> i (D Ow <br /> Plot Plan on Reverse Side) <br /> kL <br /> FOR DEPART ENT USE ONLY <br /> PHASE'II =�� $� <br /> r Application Accepted By I f Date__ <br /> i Additional Comments: ° <br /> r` Phase NI Final Inspection <br /> a II.Grout Inspection `�� <br /> Inspection By Date Inspection By % Date .. <br /> fee is Due: El ANNUALLY []'PER UNIT ❑ PER SITE ❑ EACH ❑January 1 &Received By January 31 ❑-July 1 &'Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE AMOUNTDUE CHECKED <br /> BASET EXPLANATION DATE DATE REMITTED AMOUNT <br /> Ii <br /> D <br /> FEE <br /> t: LESS - +" W - <br /> PRORATION SLI <br /> - PLUS-.. <br /> PENALTY i G� <br /> OTHER 1 <br /> ' OTHER - <br /> --v u 13 <br /> Received by Date Receipt No. Y Permit No issue cc Pate Mailed Delivered <br /> STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES` 1601 E.HAZVLTON AVE.,P.O.Box 2009 <br />