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T Applications Will Be Processed When Submitted Properly Completed.Be sure i o bign I ne.,NNS..a°°�°•• <br /> IFOR F — I APPLICATION <br /> PUMP&WELL <br /> (For Non-Transferabje,Revocable,Suspendable) <br /> - u ENVIRONMENTAL HEALTH PERMIT <br /> !DO-2- <br /> (COMPL2GraG <br /> TE IN TRIPLICATE) t S �,d•1T�.�,Go,�"AUAUTY .,•_, �,t ,I,� O, ^� dd�� <br /> Ito construct and/orinstalltheworkhereindescribe This application is <br /> Application is hereby made to theSa'nJoaquinLocalHealthDistrictforaper <br /> :. <br /> made in compliance with San Joaquin County Ord mance o. 1 2 end the�f�Les and r g lot+ons of the San J aquin Local Health District. <br /> p /' City/Town , <br /> I Exact Slte Address ! <br /> I _ + a• ° Phone <br /> r <br /> owner's Name Iz' �' <br /> Phone,.., <br /> es^' City I" <br /> Address ; <br /> Contractor's Name License* a% Business'Phonef <br /> t+. :" •'Emergency-Phone <br /> Contractor's Address t rTc'- No <br /> Is Certificate of Workman's Compensation+I�ns 'ranee on File With SJLHD? Yes, <br /> TYPE OF WORK (CHECK): NEW WELL DENT❑❑ OTHER R ND1Tl0 U❑P INSTALLATION ❑❑ PUMP REPAIR C1 <br /> WELL CHLORINATION❑ WELL ABANDONMENT Wd.0 <br /> REPLACEMENT 13 Jitic <br /> I_4 _ pit Pri DISTANCE TO NEAREST: Tank ~—�— Sewer Lines v1' <br /> Sewage Disposal Cesspool/Seepage Pit Other <br /> Property Line — Private Domestic'Well Public Domestic Well <br /> INTENDED USE �I TYPE OF WELL 9Q > f f <br /> L1 INDUSTRIAL ❑ CABLE TOOL. Dia, of Well Excavation �! <br /> ,�r�� ❑ DRILLED Dia. of Well Casing <br /> � DOMESTIC/PRIVATE <br /> I'll DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Y^"^ <br /> ❑ IRRIGATION <br /> ❑ VEL PACK Depth of Grout Seai <br /> , GRA <br /> 1:1CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL El OTHER Other Information <br /> • • <br /> ❑ GEOPHYSICAL Surface Seal Installed .y: — <br /> I _ <br /> PUMP INSTALLATION: Contractor Y <br /> Fi-P. <br /> Type,of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: O.-State Work Done <br /> DESTRUCTION OF WELL: <br /> Well DiameteP Approximate Depth t <br /> -"Describe Material and Procedure t <br /> certify that I�?have prepared tfiis application and that the work will be done'in accordance with San Joaquin County <br /> I hereby <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"1 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 wdrkman's,compensation laws of Californias <br /> k for this <br /> Contractor's hiring cinsub-contracting signature certifies the following:"I certify that in the performance of the wor <br /> permit is issued, I shill employ persons subject to workman's compensation laws of California. <br /> I will Call for a Grout;lnspection prior to grouting and a final inspection. l <br /> i Title: Date: <br /> Signed X " <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR <br /> /DEPARTMENT USE ONLY <br /> ASE I � - i/J/J, !'�[7, Application Date Accepted By.,ditional Comments.Tfk' Phase Ill Ina, Inspection.Phase 11 Z4rout-lnsQectton" : .Date <br /> Date Inspection By <br /> —Inspection By ; <br /> � , � <br /> FCC 18 Due: ❑ ANNUAL PER'UNIT° PER ITE ❑ EACH January eceived 6y'January 31" ❑ July &ReceivedREMIT <br /> 31 <br /> II l BILLING REMITTANCE .S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE i DATE REMITTED, AMOUNT <br /> FEE — <br /> LESS <br /> PRORATION - - <br /> PLUS - - <br /> PENALTY r <br /> OTHER ,l <br /> OTHER �� - f• <br /> Permit No. - Issuanc Date Mailed Delivered <br /> + Received by pato r Receipt-No.'-- �- ._. <br /> STOCKTON,CA 95201 <br /> O: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZHLTON AVE.,P.O.BON 2909 <br /> APPLICANT—RETURN ALL COPIES T — <br /> x <br />