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Applications,Will Be Processed When SuAPPL�L.AT�ON <br /> dProperlyComplex— ow01- -W­ <br /> FOR OFFICE USE: <br /> (For Non-Transterable, Revocable,Suspendable) PUMP&WELD <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Z WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application Is <br /> made in compliance with Sa oa hin County Ordinance No. 1662 and t e rules and regulations of the SalJo uin cal Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name S 2 Z� City <br /> Address4� S�� Business Phone_ _3 ax l°� <br /> Licens '—� <br /> Contractor's Name . Emergency Phone A <br /> Contractor's Address �-- No V` <br /> is Certificate of Workman's Compensation Insurance on Fil Wi h SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL C3 DEEPEN RECONDITION❑ ❑ P DESTRUCTION INSTALLATION El <br /> REPAIR__ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <br /> OTHERREPLACEMENT❑ �i, ! � 10 Pit Privy Q <br /> Q Sewer Lines <br /> DISTANCE TO NEAREST: 5eptic Tank Other <br /> Sewage Disposal Field •� Cesspool/Seepage Pit <br /> Prolperty Line Private Domestic Well <br /> Public Domestic Well <br /> M INTENDED USE TYPE OF WELL <br /> Dia. of Well Excavation <br /> ❑ INDUSTRIAL 1:1 CABLE TOOL <br /> 11 DOMESTIC/PRIVATE 11 DRILLED Dia. of Weil Casing <br /> 11 DOMESTIC/PUBLIC 1 ❑ DRIVEN Gauge of Casing <br /> 1 1:1 IRRIGATION ' 11 GRAVELPACK Depth of Grout Seal <br /> I13ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION Other Information <br /> ❑ DISPOSAL ❑ OTHER <br /> 1 Surface Seal Installed By: <br /> 11 GEOPHYSICAL ^ <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> i PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> ! Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure C <br /> t <br /> 1 hereby certify that.l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state ;awls, 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 ijmploy any person in such manner as to become subje <br /> ct 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 /> IIS <br /> 1 will Citor Grou`Inspection prior to grouting and a final inspection. <br /> Date: <br /> _ Title: <br /> Signed X _ i '�-� <br /> (Draw Plot Plan on Reverse Side) <br /> I� <br /> �i. FOR DEPARTMENT USE ONLY <br /> PHASE 1 Date <br /> Application Accepted By- <br /> Additional Comments: I�i <br /> Phase 11 Final nspection <br /> Phase 11 Grout Inspection Date <br /> Inspection By <br /> IM, Date Inspection By <br /> I Fee IS Dile: El ANNUALL I�. PER UN4T ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 C] July 1 &ReceiveREMITuly 31 <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> k BASE EXPLANATION <br /> BILLING <br /> DATE REMITTED AMOUNT <br /> II �� <br /> FEE S, <br /> 1 LESS <br /> F PROBATION <br /> PLUS <br /> PENALTY I� <br /> OTHER t �� <br /> OTHER I� <br /> [ IM, anc Date - Mailed —Delivered �� 9 <br /> F !IhDale Receipt No. Permit No. / — <br /> Received by C 1601 E.HAZELTON AVE..P.O.Bo=2009 STOCKTON,C 9 01 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> , ii <br />