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Applications Will Be Processed When Submitted Proper y omp a .� <br /> � j�'USE: <br /> FORr `APPLICATION <br /> f , ' (For Non-Transferable, Revocable, Suspendable) pUMP,&WELL <br /> ENVIRONMENTAL HEALTH PERMIT = : s <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health <br /> made in compliance witb_W Jo ui Gounty O once No. 1862 and th rules and regulations the 5a in L 1 Heal h District. 1 <br /> ICity//Town 1 <br /> Exact Site Address ® ` i <br /> Phone t o f <br /> Owner's Name City <br /> Address i ! r Business Phone <br /> Contractor's Name License <br /> Emergency Phone . <br />` Contractor's Address , J No <br />![ Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes �} <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line_ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ IND•-USTRIAL 11 CABLE TOOL Dia. of Well Excavation A/ <br /> i2 INDOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 13 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal h71 <br /> Type of Grout I` <br /> 11 CATHODIC PROTECTION L�'fARY o <br /> 1:1 DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL <br /> Surface Seal Installed By: <br /> ' <br /> PUMP INSTALLATION: Contractor H.P. 7� <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 <br /> I 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 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> llowing:"I certify that f California." <br /> the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the fo <br /> permit is issued, I shall empl ersons subject to workman's compensation laws of <br /> I will call for a Gro a f1 or to grouting and a final inspection. <br /> 1 Title:. �i ,Q. Date: <br /> Sign �\ <br /> (Draw Plot Plan on Reverse Side) <br /> if <br /> F DEP RTMEN USE ONLY <br /> t PHASE Imo . f Date y <br /> Application Accepted By <br /> Additional Comment <br /> r u spection ', Phase 111 Final Inspection <br /> hose I <br /> 6 spection By Date <br /> Inspec Ion By <br /> ALPER UNIT © PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> Fee IS Due: 13 ANNULY ❑ <br /> _ BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> l BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 143 f <br /> l FEE 3•Q'n -' <br /> LESS <br /> PRORATION ss{ <br /> I PLUS i <br /> F PENALTY <br /> -OTHER <br /> OTHER <br /> Ire B 4 0 4 (zlk 73 <br /> Dat Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by :1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES _ <br />