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Applications Will Be Processed When Submitted Properly Compieieu <br /> APPLICATION <br /> FOR OFFICE USE: f' (For Non-Transleraple,Revocable,'Suspendable) PiJMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT` <br /> WATER.QUAL�TY _ „ I-SI —C7 U. 3 <br /> (COMPLETE IN TRIPLICAthew <br /> TE) �� 1? - <br /> [3J u� Ilcation is <br /> Application is hereby made the an Joaquin Local Health Dis 1862 andtrictforaphe rules and regulations ottthle San Jo quinork t Local HeaahTD District. <br /> made in compliance with SanJoaquinCounty Ordln City/Town <br /> lot <br /> Exact Site Address <br /> ' 1,i `' Phone <br /> Owner's Name City [� 1674 <br /> Address <br /> y <br /> + Address � V License Business Phone: r <br /> :•` <br /> M Contractor's Name Emergency Phone _ h <br /> Contractor's Address ' s No - o <br /> Is Certificate of Workman's Compensation insurance_on File With JLHD? Yes�(_` I <br /> TYPE OF WORK (CHECK):' NEW WELL❑ DEEPEN❑ -RECONDITION ITI P MP INSTALLATION <br /> p' PUMP REPAIR � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OT <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool a Pit Other <br /> Cool/Seepag <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line <br /> -1 Private Domestic Well <br /> TYPE OF WELL + <br /> 4 "INTENDED USE . . 13 -CABLE TOOL -Dia. of Well Excavation ' <br /> j ❑ INDUSTRIAL '" ❑ DRILLED Dia. of Well Casing ; <br /> l (K DOMESTIC/PRIVATE -19 <br /> DRIVEN ! Gauge of Casing- <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal. <br /> ❑.IRRIGATION $ ROTARY Type Of Grout <br /> 13CATHODIC PROTECTION El DISPOSAL Other Information <br /> DISPOSAL Surface Seal installed By:, # Q <br /> ❑ GEOPHYSICA(- Q <br /> PUMP INSTALLATION:: <br /> Contractor �F H.P. <br /> Type of.Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT:' � ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> j Describe Material and Procedure <br /> -wiI hereby certify that I have prepared this application <br /> the SanttheJoaquin work <br /> ail Heall be th District one in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations <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 orsub-contracting signature certifies the following:"I certify that in the performance of the work iorwhich this <br /> jpermit is issued, i shall employ persons subject to workman's compensation laws of California." <br /> I will 11 for a Grout Inspection prior to grouting and a final inspection. pate: <br /> —leyl <br /> Title-. <br /> Sig ed"F ( ra tan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> P E � ll Date <br /> ± Application Accepted By <br /> Additional Comments phare III Fina Inspection <br /> Phase 11 Grout inspection Date 0, f I <br /> ' Inspection By <br /> Inspection By Date <br /> F <br /> ❑ PER SITE EACH, `[3,January 1 &Received By January 31 ❑-July i &ReceivedREMIT 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNITCHECKED <br /> _ <br /> BILLING' REMITTANCE � - AMOUNT DUE <br /> 1RggE -- * EXPLANATION - DATE DATE REMITTED AMOUNT <br /> r <br /> FEE <br /> LESS _ <br /> PRORATION <br /> 'PLUS <br /> PENALTY: - - '"`•` <br /> OTHER { -� <br /> OTHER <br /> i Mailed ZOOS Delivered - <br /> Permit NO -. Iss nce Dat <br /> Received by _ - 'M�•'`'Date•- - Receipt No. -'- 1691 E.Hp, ox STOCKTON,CA 95241 {i <br /> ZELTON AVE..P.O.S <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />