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+� III bure iv olull I... <br /> Applications Will Be Processed When Submitted Properly omp e e <br /> �F� . s APPLICATION <br /> OR OFttE USE: rIIII 7 ' <br /> ELL <br /> (For Non-Transferable, Revocable, Suspendable} PUMP&W >� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY .,"Y <br /> (COMPLETE IN TRIPLICATE) <br /> Application is herebymadetotheSa"n Joaquin Local HealthDistrictiorapermit toconstruct and/orinstalbthework.hereindescribed.Thisapplicationls <br /> made in compliance with San Joaquin County Ordinance No.1862 a d he rules and regulations City/Town <br /> of the San J aquin Local Health District. <br /> III <br /> Exact Site Address I?City S <br /> GS�_ f! Phone L <br /> Owner's Name ark*, City <br /> Ad d ress <br /> . L'Icense#3 �� Business Phone <br /> Contractor's Nam a _ z ;yx ergency_Phone t'' �� a, <br /> Contractor's AddressNo <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes W <br /> TYPE OF WORK (CHECK❑)'. IE WELL <br /> ABA OINMENT ❑❑ OTHER R 13 ITIO UMP INSTALLATION-53'I PUMP REPAIR❑ <br /> I WELL CHLORINATION , <br /> REPLACEMENT❑ I �a IJ <br /> C �F 7� Pit Priv fr <br /> DISTANCE TO NEAREST: Septic Tank 6 f Sewer Lines Aloe <br /> `Y .k x <br /> Sewage Disposal Field A&Aj4= Cesspool/Seepage Pit /v� ey �tl� <br /> Property Line :Private Domestic Well <br /> Public Domestic Well <br /> ' TYPE OF WELL �a <br /> El INDUSTRIAL N <br /> INTENDED USE <br /> LE TOOL Dia. of Well Excavation <br /> MESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing's <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN <br /> Gauge of Casing I`�_< <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Sea(l, <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> i ❑ OTHER Other Information'""'-- - <br /> ❑ DISPOSAL <br /> ❑ GEOPHYSICAL Surface Seal 'Installed_By: ; F �` m �r��.c� <br /> Contractor o L o s/ ,C.l -A. <br /> PUMP INSTALLATION: -j-H-P. I� <br /> TYPe of Pum <br /> PUMP REPLACEMENT: ❑ State Work-Done <br /> 13State Work Done r <br /> PUMP REPAIR:- _ Approxi ate�Depth <br /> DESTRUCTION\OF WELL: Well 'Diameter . _► �, 4- <br /> I / ":v <br /> t Describe Material and Procedure �ti } <br /> / ,. ? 11 t , <br /> } <br /> I hereby certify that I have prepared this application and that the work will be,adone in accorda t e 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:"l certify that in the eot to woe kmanformas compensnce of the at, laws of Califork for which this rnia." <br /> f is issued, I shall not employ any person in such manner as to become subl <br /> Contractors hiring arsob-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> laws of California." <br /> permit is issued, I shall employ persons§object to workman's compensation E" <br /> call fora Gro spection prior to gt uting and a final inspection. �^ <br /> Title: �� Date: <br /> Signed -�- <br /> (Draw Piot Plan on Reverse Side) <br /> j FOR DEPARTMENT USE ONLY <br /> � 8 <br /> ' PHASE I { ` Date <br /> Application Accepted'Byf y L1" - A <br /> Additional Comments: - <br /> 1 Inal 1lispectlon'�'^ <br /> Pha II G out inspection (� .y <br /> I _�nspectlo <br /> Date <br /> inspection By ate Y. <br /> Fee IS Due: ❑ ANNUALLY [3 PER UNIT --_-❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received By July 31 <br /> REMIT <br /> t BILLING REMIITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION HATE DATE REMITTED AMOUNT <br /> FEE t <br /> LESS i H <br /> PRORATION <br /> : <br /> PLUS SS ✓ �� - - <br /> PENALTY 3' , <br /> J), <br /> OTHER !'.�• '' <br /> OTHER f . <br /> Receipt No. <br /> Permit No <br /> issuance Date Mailed Delivered <br /> Received by ate y 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 85201 <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />