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' Applications Will Be Processed When 5ubmtttearropCrlr ^•r <br /> = r% APPLICATION <br /> FOR OFFICE USE: f PUMP&WELL' <br /> � Y � (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY applicationwork is <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetotheSan Joaquin LocalHealth <br /> N Districtfora <br /> and pthe ruloconstruct <br /> r gulattiions oftal thethe San Joaquinln ocal Heatl Dist.This t <br /> made in compliance with San Joaquin/County Ordity/Town <br /> k Exact Site Address . Phone <br /> Owner's Name City ' <br /> Address �D ¢bUt{/License "�f3usiness Phone <br /> p�L� # <br /> Contractor's Name Emergency Phone Q <br /> Contractor's Address7deNo 1 <br /> is Certificate of Workman's Compensation Insurance on File❑With 5J ECpND1T10N DESTRUCTION❑ 03 <br /> j TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ PUMP REPAIR <br /> r ❑ WELL ABANDONMENT❑ OTHER 13 -PUMP INSTALLATION <br /> WELL CHLORINATION <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> k DISTANCE TO NEAREST: septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field - ...- Public Domestic Well <br /> Property Line Private Domestic Well <br /> FTYPE OF WELL <br /> INTENDED USE 13 CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing' <br /> ❑ DOMESTIC/PUBLIC �` Depth of Grout Seal <br /> C�9 IRRIGATION ❑ GRAVEL PACK .' Al <br /> ❑ ROTARY Type of Grout <br /> C1 CATHODIC PROTECTION ❑ OTHER Other Information <br /> i ❑ DISPOSAL Surface Seal installed By: <br /> ❑ GEOPHYSICALk_ <br /> i. PUMP INSTALLATION: Contractor, r t H P <br /> Type of Pump <br /> ❑ State Work Done ' <br /> PUMP REPLACEMENT: d <br /> F PUMP REPAIR: �.State Work Dane Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> i <br /> San Joaquin County <br /> I hereby certify that I have prepared this application and'that the work will be done in accordance with <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> r; <br /> such manner as to become subject to workman's compensation laws of California <br /> is issued, I shall not employ any person in .:„ <br /> ollowing:"1 certify that in the performance of the work forwhich this <br /> Contractor's hiring or sub-contracting signature certifies the f <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r I Ill call for a Grout Inspection p i rutin d final inspection. �Y <br /> k tie: Date: t <br /> Signed X � - (Draw Plot ari on Reverse Side) <br /> I <br /> ORD PARTM T USE ONLY <br /> �d <br /> PHASE I Date 5 . <br /> A 1-e-•. <br /> Application Accepted By <br /> Additional Comments: Phase HI Final Inspection <br /> t Phase N Grout Inspection Date <br /> Date Inspection By <br /> Inspection By 4 <br /> Fee IS Due'. ANNUALLY ❑ ❑ EACH .. El January.1 &Receiv y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> PER UNIT PER 517E <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I i - <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> � y <br /> OTHER <br /> r o s5c�177 a8 B a <br /> Mailed Delivered <br /> Receipt No. ,Permit No. CA 9520t <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.B*x 2009 STOCKTON, <br /> APPLICANT—RETURN ALL OPIES TO: ENVIRONMENTAL HEALTH PEiIMITlSERVICES <br /> - ( _ <br />