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.. .. . . <br /> A.pplications Will Be Processed When Submitted <br /> APPLICATION <br /> FOR OFFICE USE: (For Non-Transferable, Revocable, Suspendable) pUMP&WELL <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) <br /> o. 1862 and the rules and regulations of the San J quis Ea Health District. <br /> Application is hereby made to San Joaquin Local HealtfllDistrictiora permittoconstruct and/or install the herein described. Is <br /> wrE <br /> made in compliance with San Joaquin County u0rdinaT � © City/Town <br /> Exact Site Address, IQ� — , phone <br /> 1 Sir�L� City EINE-N' C H <br /> Owner's Name `� t <br /> Address ^ ����_�_ Business Phone <br /> V L`��, ���. � License#� <br /> Contractor's Name Emergency Phone <br />� z,lp�__E. t No <br /> I Contractor's Address <br /> ❑ RECONDITION 13 DESTRUCTION❑ <br /> Is Certificate of Workman's Compensation Insurance File With SJLHD? es <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN <br /> WELL <br /> CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> t REPLACEMENT 11L ` Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> TYPE OF WELL I Q <br /> INTENDER USE ❑ CABLE TOOL Dia. of Well Excavation G y <br /> ❑ I STRIAL ❑ DRILLED Dia. of Well Casing <br /> Z. <br /> DOMESTIC/PRIVATE 11 DRIVEN Gauge of Casing r <br /> ❑ DOMESTIC/PUBLIC ❑ GR L PACK Depth of Grout Seal �` 0 <br /> ❑ IRRIGATION OTARY Type of Grout r <br /> 11 CATHODIC PROTECTION Other information <br /> ❑ DISPOSAL ❑ OTHER <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> � Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT <br /> PUMP REPAIR: ❑ State Work Done <br /> _ Approximate Depth <br /> k <br /> DESTRUCTION OF WELL: Well Diameter <br /> { <br /> � 1 GC,A)IV-4 Describe Material and Procedure <br /> plication and that the work will be done in accordance with San Joaquin County <br /> I hereby certify�aTI�ve prepared this ap <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:"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 torwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i I will call for a Grout inspection for to routing and a final inspection. Date: ZG <br /> Title: <br /> t Signed X (Draw Plot Plan on Reverse Si e <br /> !` FOR DEPARTMENT USE ONLY -V <br /> r <br /> f Date&0 6 <br /> k pHASEI <br /> i Application Accepked By <br /> f Additional Comments: Ph Final I ectlon / /p <br /> Pha Grout In ection _ Date <br /> inspection By <br /> ate �U Inspection By <br /> ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> Fee Is Due: Cl ANNUALLY ❑ PER UNIT .❑ PER SITE EACH <br /> REMIT <br /> -EXPLANATION DATE REMITTANCE $ - AMOUNT DUE CHECKED <br /> BASE E ' BILLING REDATE REMITTED - AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> { OTHER <br /> _ 4ssuance DaSe Mailed Delivered <br /> Receipt No. - Permit Na. CA 95201- <br /> • Received by Date r 1601 E.HAZELTON AYE.,P.O.Boy 2009 STOCKTON, <br /> - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />