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Applications Will Be Processed WhenSubmitted ProperlyGompiemu. 1—amu <br /> FOR OFFICE t<SE: APPLICATION + 7 �4 <br /> (For Non-Transferable, Revocable,Suspendable) I PUMP& <br /> ENVIRONMENTAL HEALTH PERMIT �y MAY 22 1981 <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtfora per <br /> mitto construct and/or install tt^r"crk hre.pgd� rif� d application is <br /> made in compliance with a Joaquin Cunty�Ordinanc�No t8 2 and t e rules and regulations of the S tJ Tui t 5 1 &ff district. <br /> Exact Site Address �� Ic-o City/Towne <br /> r Phone (e " s <br /> Owner's Name <br /> Address City � � <br /> Contractor's Name , <br /> License#��� Business Phone Q <br /> Emergency Phone <br /> Contractor's Address <br /> { <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRL�' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 1 <br /> 6 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 ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL S face Seal Insta led By: <br /> PUMP INSTALLATION: Contractor „ <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ii� 17 <br /> d-� <br /> PUMP REPAIR: o-state Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 Y(n <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 /> 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 persons subject to workman's compensation laws of California." <br /> I will C for a Grout 1 ction prior t grouting and a final inspect f <br /> Signed X Title: Date: <br /> (Draw Plo Ian on Revers ide] <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: g�� <br /> base II Grout Inspection 'IIP a IN Fin inspection <br /> Inspection By <br /> ri Date Inspection By v Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> D <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> o, Permit No. suance to <br /> Received by Date Receipt NMailed Delivered <br /> . APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95281 <br />