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Appi s <br /> tiCatlons"Will Be ProcesSeit When'.Submitte rop <br /> ;. APPLICATION <br /> FOR OFFICE USE: (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> NVJRONMENTAL HEALTH PERMIT <br /> SIAs° WATER QUALITY applicationhereis <br /> (COMPLETE IN TRIPLICATE)i�L- r : itto construct.- <br /> A plication is hereby made to the San Joaquin Local Health District1862or Perm <br /> a ules and regulations oftthe S n Joaquin Local He�the work ah District..This <br /> Application Or ante c5 � <br /> made in compliance with S�Joa uin CtY City/Town , <br /> Exact Site Ad a� Phone <br /> TU <br /> Owner's Name city Aj <br /> Address -2-M 119 Bu r Phone <br /> �J License# 2� <br /> Contractor's Name c Emergency Phorrg <br /> Contractor's Address <br /> /«] N o <br /> Is Certificate of Workman's Compensation LHD? Yes <br /> Insurance on File With SR CONDITION 13DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN <br /> WELL CHLORINATION 11 WELL ABANDONMENT 13OTHER ❑ PUMP REPAIR <br /> PUMP INSTALLATION❑ <br /> REPLACEMENT Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL Dia. of Well Excavation <br /> C1 INDUSTRIAL ❑ CABLE TOOL <br /> ❑ DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor H.P. <br /> PUMP INSTALLATION: Type of Pump cS' G <br /> 4 T ,�nr S 7.zLL <br /> 51 State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth �. <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> 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. which this f <br /> Home owner or licensed ageni's signatuercertifies uch manner tobecomesubject to workman's compensation y that in the performance of the work for <br /> of California." <br /> is issued, I shall not employ any persong,111 tthat <br /> in the <br /> Contractor's hiring or sub-contracting subjere ct to workman's following. <br /> l ompensat on awsof California." of the work for which this <br /> permit is issued, I shall employ persons1 <br /> I w' all for a Grou 4pen prior to grouting and a final inspe <br /> . - ,-k- Date: <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted ` <br /> Additional Comments h e 111 Final�Inspectn� <br /> Ph se 11 Grout Inspection Inspection By Date <br /> Inspection By Date <br /> 31 <br /> January REMIT <br /> Fee Is Due: EI ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH REMITTANCE t &ReceiveSd By January 3iAM01❑NTJDUE &uly 1 Recei�HECKEOed By y <br /> BILLING <br /> BASE EXPLANA740N HATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Issuance Date Mailed Delivered ' /� <br /> Receipt No. Permit No. STOCKTON,CA 95201 -} <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Baa 2M f 4 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />