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Applications Will Processed When Submitted roper - <br /> FOR OFFICE USE: �� I�. APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH.PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Districtforapermittoconstructand/or install the work herein described.This <br /> rictapplication ls <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin ocal a th District. <br /> _ A J6 City/Town <br /> I Exact Site Address �� X } � <br /> /n V d n� Phone <br /> A 14011, 111) It Owner's Name City <br /> Address +.9_ 3^�1,�"" Business Phone 6 I— — 74, /w <br /> Contractor's Name �k � License#�� <br /> ^� A11®- Emergency Phone <br /> i Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X_._ <br /> TYPE OF WORK (CHECK): NEW WELL❑ [DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER El 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 /> i" <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ <br /> DOMESTIC/PRIVATE <br /> ❑ 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 y k <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL !s .Surface SealInstalled By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> C <br /> _ PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: V State Work Done �'� C <br /> Well Diameter <br /> DESTRUCTION OF WELL: Approximate Depth i <br /> � Describe Material and Procedure c <br /> ( I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject.to workman's compensation laws of California." <br /> I will call for a Grout Inspection rio to gr and a final inspection. <br /> itle: Date: <br /> ' Signed X �' <br /> (Draw Plot Ian on Reverse Side) <br /> t ; <br /> ORD PARTME T USE ONLY <br /> t p- q <br /> PHASE I Date p 7/ <br /> —Application Accepted By <br /> Additional Comments: <br /> F Pfia <br /> Phase II Grout InspectionInal Inspection <br /> ! <br /> f Inspection By Date <br /> Inspection By Date <br /> Fee Is Due: 11U <br /> ANNUALLY ❑ PER NIT ElPER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Receiv REMIT"y 31 <br /> F BILL4NG REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> t FEE y� <br /> F LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> 3 � - <br /> I. x1Receipt No Permit No,,_, Issuance Dae>_ -.Mailed Delivered <br /> Received by a�' Date <br /> 1601 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />