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- `-'Applications�WiN Be Processed When Submitted Properly Completed.Be sure Io atgg <br /> FFICE USE: APPLICATION 7 o` <br /> (For Non-Transf;rable,Revocable,Suspendable) PUMP&�1W11Ett <br /> I' ENVIRONMEN'CAL HEALTH PERMIT <br /> WATER QUALITY ; • ; t-• a , <br /> aMPLETE IN TRIPLICATE} <br /> Application is hereby madetotheS lnJoaqufrt Local Health Dist'i8cSt2oantlAerniitto construct he rules and regulations of the San Joaquin lLocal Health Districplication is <br /> made in compfiancewith San_Joagllin County Ordinance No City%Town <br /> y 5 .-,t� - _ ... <br /> Exec a Address09 pbbna <br /> C.9 - <br /> Owneies NS e c : City' <br /> Address a. 3 v: License#`Z Business Phone <br /> Contractor's NamePhone <br /> I <br /> iM •. ;.�.. -, ._:,:1 ..� , <br /> Emergency n <br /> I Contractor's AddressNO <br /> Is Certificate of WorkmaKomp�ern�sation Insurance on Fite With SJLHD? Yes_D ' "DESTRUCTI""O,N13 <br /> TYPE OF WORK (b'HECK): NE.W WELL❑- DEEPEN❑�a OTHERRECITI-PUMP-1NSTALLATION� PUMP REPAIR❑ <br /> WELL CHLORINATION❑ ALL ABANDONMENT <br /> REPLACEMENT l] '` Sower lines Q Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Wefl <br /> Public Domestic Well <br /> i' <br /> INTENDED USE TYPE OF WELLj pia. of Well Excavation <br /> ❑ 1 STRIAL ' ❑ CABLE TOOL X.. <br /> ❑ DRILLED Dia,of Well Casing <br /> ts ' <br /> DOMESTIC/PRIVATE 0 DRIVEN Gauge of Casing - <br /> ❑ DOMESTIC/PUBLIC Depth of Grout Seal <br /> ❑ IRRIGATION P ❑ GRAVEL PACK <br /> fl ROTARY Type of Grout . <br /> ❑ CATHODIC PROTECTION Other Information <br /> ❑.DISPOSAL OTHER <br /> � -Surface Seal nstalled By. <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: � <br /> In State Work Done <br /> ❑ State Work Done '- <br /> PUMP REPAIR::" Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> E Describe Material and Procedure <br /> 1 hereby certify that i have prepared this application nd that <br /> Jothb e Joaquin work <br /> will <br /> i Health Disone In accordance with San Jaaquin'County <br /> ordinances,state laws,and rules and regulations of theq certif that in the performance of the work forwhich this permit <br /> Home owner or licensed agent's signature certifies the following:' Y <br /> is issued, t shalt not employ any person in such manner as to become subject to workman's compensation laws <br /> California." <br /> Contractor's hiring or sub contracting signature certifies the following:,"I certify that in the performance of the work forwhich this <br /> permit is issued, 1 shall employ persons subject to workman's,compensation laws of California." Q <br /> ' 1 will or Groutl ctlon prior to grouting and a final inspection. <br /> Date:� =f <br /> Title: , <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> . FOR DEPARTMENT USE ONLY <br /> _,00:r '0, . <br /> PHASEI ­ Date----=r <br /> Application Accepted By r <br /> Additional Comments: I' ;nal Inspection <br /> a Wr <br /> Ph se it Grout Inspection ,Date <br /> 1 Inspection By <br /> _ Date Inspection By <br /> t ❑iPER UNIT ❑ PER SITE EACH <br /> E3REMIT <br /> January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> %Fee Is Due:D ANNUALLY• , CHECKED <br /> REMITTANCE $ JIAROUNS DUE <br /> - Ef ' EXPLANATION B1Lt1NG DATE REMITTED AMOUNT <br /> BA <br /> DATE <br /> t FEE II <br /> LESS w i <br /> PRORATION * *.PLUS • <br /> PENALTY I -i•.. . <br /> OTHER <br /> OTHER t ^ t �•` .. t i /�'/ <br /> (f//� s tSSuei1(B ,VfOdte Mailed Delivered <br /> Date - •Receipt Na. --� - Permit No.' STOCKTON.CA 9=1 <br /> Received tly 1991 E•HAZELTON AVE.P.O.9ml 2009 <br /> APPLICANT—RETURN ALL�OPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -•�,,, _ <br /> ' 111' <br />