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i 1 ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. y <br /> :OR OFFICE USE- APPLICATION <br /> ;•' 4 (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) tC»p r-WATER QUALITY <br /> Application is hereby made to the San lJoaquin Local Health Distbet01 fora permit toconstruct and/or install the work herein described.This application is <br /> l made in compliance with Sa J_oaquin Count rdinan p."186 and the rules nd regulations of the San a uin Local Health District. <br /> F _ _. <br /> Exact Site Address e` City/Town <br /> li cr <br /> Owner's Name Phone <br /> Address �W - <br /> City - <br /> Contractor's Name No_ License#��i Business Phone�_fp <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes-,,� NO <br /> TYPE OF WORK (CHECK): NEW WELL ElDEEPEN ElRECONDITION 13DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP 1NSTALLATIONJ;4 PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy , } <br /> Sewage Disposal Field I` Cesspool/Seepage Pit - - Other ' <br /> II Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL r <br /> ❑ INDUSTRIAL ❑ <br /> GABLE TOOL, Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ <br /> DRIVEN !3� Gauge of Oaring � <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> y Type of Grout _t <br /> ❑ DISPOSAL ❑ OTHER Other Informisk Iled By: <br /> ❑ GEOPHYSICAL <br /> Surface <br /> PUMP INSTALLATION: Contractor X1 H.P. <br /> I; Type of Pump,_ - eb <br /> _- <br /> PUMP REPLACEMENT: ❑ St '_ Done_, <br /> PUMP REPAIR: tate Work Done Approximate Depth <br /> DESTRUCTION OF.WELL:: ^�lnran cr. .�y�"`" y .. <br /> Describe M re <br /> t _ I <br /> " ared this application and that the work will be done-in-accordance with San Joaquin County <br /> l?hereby certify that I•have-prep <br /> dinances, state law5'and_r`u`jl3s and regulations of the San Joaquin Local Health District <br /> Home ow s, state. <br /> licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> �r is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> g g g:,: <br /> Contractor's hiring Or sub-contracting signature certifies the following: 1 certify that in the performance of the_work forwhich this �f <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." .� <br /> 1 will all for a Grout inspection prfov~to grouting and a final inspection. <br /> II rn Title: ��LAN Date: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> i FO DEP TMENT E ONLY /. <br /> PHASEI Date `7 y <br /> Application Accepted By <br /> 'Additional Comment_s:, <br /> P se f Final I pection <br /> Phinspection B <br /> Phase II Grout Inspection f Date d <br /> Il Inspection By Date. <br /> /✓ <br /> Fee Is Due: ❑ ANNUALLY [3 PER UNIT PER SITE El EACH ❑ January 1 &Received By January 3S July 1 S Receiv REMIT <br /> YuIy 31 <br /> ^ BILLING REMITTANCE $ AM NT DUE CHECKED <br /> ASF EXPLANATIO DATE DATE REMITTED AMOUNT <br /> ,j <br /> i' <br /> dFEE <br /> III'LESS <br /> IiPRORATION' _ F <br /> $PLUS <br /> PENALTY <br /> i 1OTHER <br /> OTHER - <br /> _ Issuance Date Mailed Delivered <br /> ' Receipt No. Permit-No. CA 95201 <br /> t E� Received by Date - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON; <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 4 <br />