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Applications W111 Be Processed When Submitted <br /> rTIONpleted Be Sure IQsign I <br /> 'fOR OFFICE USE: Y. <br /> (For Non-Transferable, Revocable, Suspendable) PUMP &WELL <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> ,p .. -- - WATER QUALITY (O T — CSO�-(0`L_ 1 <br /> (COMPLETE IN TRIPLICATE) 'O°3 =I-eX;..1-5-7 " <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance th San oaquln County Ordinan e N . 1862 and the rules and regul tion Yof the San Joaquin Lo alb ieaith District. <br /> Exact Site Addres �j <br /> Phone <br /> Owner's Name 7- III Ciky <br /> Address License 42&jl . Business Phone �T <br /> Contractor's Name i <br /> Emergency Phon <br /> Contractor's Addres e on File With SJLHD? Yes No Q� t <br /> Is Certificate of Workman's Compensation Insurancrr_ <br /> TYPE OF WORK (CHECK): NEW WELL. DEEPEN RECONDITION DESTRUCTION❑ ---- <br /> WELL CHLORINATION 13 WELL ABANDONME1 T � ` OTHER F-1PUMPINSTALLATION ❑ PUMP REPAIR© s <br /> REPLACEMENT❑ Pit Prtvy <br /> t <br /> DISTANCE TO NEAREST: Septic Tank -{� Sewer Lines oolhS �----- Other <br />` Sewage Disposal Field/D�l Cess e Pit <br /> p ree pa 9 <br /> Property Line/0-If—Private Domestic Well - <br /> Public Domestic Well <br /> Line/0-If— <br /> TYPE OF WELL <br /> INTENDED USE .v X <br /> C3 INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> [1 <br /> DOMESTIC/PRIVATE 1-1DRILLEDDRILLED Dia. of Well <br /> k 11DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing -44 <br /> , <br /> i IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal r <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information °P <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and.Procedure l � <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I Y Y <br /> ordinances, state flaws, 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-contract: signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall empl p r ons subject to workman's compensation laws of California." 1 <br /> I all f a ro sp o rior to grouting and a final inspection. <br /> f Title: Date: <br /> Signed X <br /> (Draw Plot Pian on Rev a Side) <br /> FOR DEPARTMENT USE ONLY <br /> f PHASE I 0_3 Date�"��� � "1 <br /> [ Application Accepted By <br /> Additional Comments: <br /> Phsill Final inspection� <br /> Phase 11 Grout Inspection pate Z G <br /> It— <br /> inspection By <br /> Date Inspection l <br /> /,/J1 i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Recei�6 Y January 31 ❑ July 1 &ReceivedREMIT <br /> uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> k Received by Date <br /> Receipt No. Permit N Iss an ate Mailed Delivered <br /> 1 7601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN'ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />