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properly <br /> Applications Will Be Processed When Su APPLICATIONPIeteBeSure ' <br /> c FOR OFFICE USE: (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> - I ENVIE ONM NTE�LTH PER�4T yL L <br /> � � LJ � fructarid�/orriinstalIthework.hereindescribed.Thisapplicationis <br />• (COMPLETE IN TRIPLICATE)�f/ <br /> Application is hereby made to the San Joaquin Local HealthDistrictfor permittocons � <br /> made in compliance ith San Joaquin County Ordinance No. and he rules and regulations <br /> Citof the San aquin Local Health District. <br /> Exact Site Address = 3 � �^ 3<.� <br /> Phone <br /> Owner's Nathe City <br /> ---------------- <br /> Address �, + 2 Business Phone-7 J <br /> 131• �- ,`j a ,du• License#� – <br /> Contractor's Name _ ,� Emergency Phone j <br /> Contractor's Address/ Yes No <br /> Is Certificate of Workman's Compensation Insurance onPF eEN ❑With SR CONDITIOND STRUCT OND ❑ ' <br /> TYPE OF WORK (CHECK}: NEW WELLED DEE <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field public Domestic Well <br /> Property Line Z t; L - Private Domestic Well <br /> ITYPE OF WELL <br /> INTENDED USE <br /> ❑ CABLE TOOL Dia. of Well Excavat <br /> 11 INDUSTRIAL Dia. Of Well Casin5��L'7 DOMESTIC/PRIVATE DRILLED [ M <br /> I DRIVEN Gauge of Casing <br /> 11DOMESTIC/PUBLIC ❑ GRAVEL PACK "Depth of Grout Seal � ° } <br /> 11 IRRIGATION <br /> (3'�IOTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal sta d By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor _' H.P. <br /> k Type of Pump <br /> ❑ State Work Done <br /> I PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ,., Approximate Depth <br /> f DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that <br /> the work Joaquin Local llbe He done D•Isin trica cordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San_ <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance otthe work forwhich this permit <br /> is issued, l 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:"1 certify that in the periormance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." . a <br /> I will call for a Grout Inspection prior to grouting and a final inso,• Date: ' <br /> Title: <br /> Signed X _ {Draw Plot Plan on Reverse Side)' <br /> e <br /> FOR DEPARTMENT USE ONLY f <br /> _ U <br /> PHASE I / Date <br /> Application Accepted By <br /> Additional comments:A t` t ' Phase III Final Inspection <br /> Phase II Groutt Inspection Date <br /> inspection By <br /> Date inspection By <br /> ThZI 31 <br /> REMIT <br /> Fee IS Due: ❑ ANNUAILLY ❑ PER UNIT• PER 517E ❑ EACH- "- -❑ January 1 &Received By January 31AMOl❑NTJDUE'uly $Received By CHECKEQy <br /> BILLING REMITTANCE REM4TTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE: <br /> LESS <br /> PRORATION " <br /> PLUS <br /> PENALTY <br /> OTHER a <br /> OTHER <br /> Mailed Delivered 201 <br /> Dat - Receipt No. <br /> Permit No. Issuance Dale <br /> R eived by '� - - - 1601 E.HAZELTON AVE.,P.O.9oti 2009 STOCKTON,CA 95 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM17lSERVICES <br />