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Applications Will Be'Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 4 APPLICATION <br /> _ © (For Non-Transferable, Revocable, Suspendable), <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> --� <br /> (COMPLETE INTRIPLICATE)7P3 �unuTrZ <br /> —0 — <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 /> F made in compliance with San Joaquin County Ordinance No. 1862 and the rule and regal s €the man J quiryLOcal HpEth District. <br /> Exact Site Address e S�t'C .1� X17 6C — �yl�-�-- It own � l <br /> Owner's Name IL Phone <br /> Address City +2h U�o f <br /> Contractor's Name License# 7XC—Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ - RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR � <br /> REPLACEMENT❑ J, <br /> DISTANCE TO NEAREST: Septic Tank Sewer LinesY.' Pit Privy <br /> Sewage Disposal Field _ .—Cesspool/Seepage Pit Other -� <br /> t <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ( „1 <br /> ❑ INDUSTRIAL ` ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing ` <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 5 IRRIGATION ❑. GRAVEL PACK Depth of Grout Seal o <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Ins alied By: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. JJ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ®=State Work Donees <br /> R � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,'state laws, and rules and regulations of the San Joaquin Local Health District. <br /> E <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-contracting signature certifies the following:"I certify that in the performance of the work forwhich this -T <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t I wiy call for <br /> ,aa Grout Inspection r outi and a final inspection. <br /> i ! ,1 tie: Date: r+ <br /> Signed X - - <br /> 1 i (Draw Plot an on Reverse Side) <br /> f <br /> F DEP RTMENT SE ONLY <br /> ' PHASE <br /> Application Accepted ey `'" Date 29' <br /> Additional Comments: <br /> t Phase 11 Grout InspectionP _ <br /> se I mal Inspection <br /> Inspection By Date Inspection B Date .4 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _ ER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 A <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED r <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATsON <br /> ". PLUS <br /> PENALTY <br /> ' OTHER <br /> OTHER <br /> ReceiVed-by Date Receipt'No. Permit No. - Isjuance ate Mailed' Delivered <br /> 16D1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON;CA 952111 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM ITISERVICES - ' <br />