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F _Applications III Be Processed When Submitted Properly Completed. Be SureTosign TneApplication. I <br /> APPLICATION <br /> FOR OFFICEIUSE: <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY X <br /> `(COMPt:ETE IN TRIPLICATE) �. <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> A made in_compliance with San JoaquiCounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local a It District. <br /> City/Town <br /> Exact Site Address <br /> M' Phone <br /> Owner's Name N <br /> City <br /> Address I <br /> C License#�4 s?.. Business Phone } <br /> Contractor's Name , 1 �I/� <br /> Contractor's Address 4 h h Emergency Phone <br /> � <br /> Is Certificate of Workman's Compensation No <br /> In rance on File With SJLHD? Yes ` <br /> TYPE OF WORK (CHECK): NEW WELL* DEEPEN ❑ RECONDITION❑ DESTRUCTION J `� <br /> WELL CHLORINATION C1 WELL ABANDONMENT ❑ - OTHER ❑ PU l INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ I C �— <br /> y Sewer Lines �d Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank .�^4 Other r— <br /> Sew' Disposal Field l� Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well <br /> I/ <br /> INTENDED USE TYPE OF WELL / Q <br /> ❑ INDUSTRIAL CABLE TOOL <br /> Dia. of Well Excavation f <br /> DOMESTIC/PRIVATE 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 Kr <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: ; <br /> PUMP <br /> INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i ❑ <br /> 4 PUMP REPLACEMENT: State Work Done <br /> 4 PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure `T <br /> I hereby certif that I have repared this application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, tat laws,,�an r les and regulations of the San Joaquin Local Health District. <br /> r <br /> Home own or lic rise' gen's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> f is issued, shall n t e,I loy ny person in such manner as to become subject to workman's compensation laws of California.' <br /> Contra vr's hirin o ub-c trading signature es the following:1 certify that in the performance of the work for which this <br /> permi is iss 11 II a play persons su , ct to workman's compensation laws of California." <br /> I will II for a out I spec on prior tdarouting and a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> f <br /> 4 FOR DEPARTM NT USE ONLY <br /> I <br /> PHASE I Date q,7 <br /> Application Accepted By 'I� <br /> F Additional Comments: <br /> Phase II nspection Phase F' ! Inspection t <br /> I: ate Inspection By Date <br /> Inspection By p9pII <br /> Fee Is Due: ❑ ANNUALLY il� ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ElJuly 1 &ReceiveRdEByl July 31 <br /> :h BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> 4 LESS <br /> PRORATION Ip <br /> PLUS II <br /> PENALTY <br /> OTHER Ili <br /> OTHER I� <br /> q - I a { -7'r <br /> I� Issuance Date Mailed Delivered <br /> Received by <br /> Date Receipt No. Permit No. <br /> I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box"20W STOCKTON,CA 952 <br />