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� pplications Wil cessed When Sutimitted-f raper y Completed. <br /> AUG <br /> ���� APPLICAT;�ON .. <br /> °FOR <br /> OFFICE U �1V <br /> r LRor Non-Transferable, Revocable, Suspendable)OCAL PIMP&WELL <br /> �q® -fg%CIENVIRONMENTAL HEALTH PERMIT f `# <br /> WATER QUALITY ' <br /> {Cplt':PLETE IN TRIPLIC <br /> Applic_4tion is hereby made to the San Joaquin Local e h District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance ith San Joaquin County Ordi a No. 18fi2 and t e r es nd egulations of the Sar�,raag1n Local Health District. 4 <br /> City/Town (�� <br /> Exact Site Address - 1 <br /> ' - Phone <br /> Owner's Name fCity _ <br /> Address G,�Business Phone `?—1 T <br /> Contractor's Name tw . �s .License#� � <br /> Emergency Phone <br /> Contractor's Addre�� ,�,�.� No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): <br /> NEW <br /> WEL NNDONMENT ❑DEEPEN ❑ OTHER ❑RECONDITIONPUMP INSTALLATION O❑❑ PUMP REPAIR❑ / n <br /> WELL CHLORINATIONVV �� <br /> REPLACEMENT❑ /f~l Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank E Sewer Lines_ Other . <br /> Sewage Disposal Field cesspool/Seepage Pit <br /> Property Line— Private Domestic Well Public Domestic Well a <br /> INTENDED USE <br /> TYPE OF WELL } �� <br /> ❑ INDUSTRIAL E"i ABLE TOOL Dia. of Well Excavation, <br /> 11DOMESTIC/PRIVATE 13DRILLED Dia. of Well Casing <br /> 13 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC y" <br /> %IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ,. Type of Grout <br /> E <br /> C1 DISPOSAL ❑ OTHER Other OthInformation <br /> .. d <br /> 13 GEOPHYSICAL Q Surface seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - <br /> fElState Work Done <br /> PUMP REPLACEMENT: <br /> PUMP REPAIR: ❑ State Work Done - <br /> 1 Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work tor-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 for which this <br /> t permit is issued, I shall employ persons subject to workman's compensation laws of California." T <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Date; • <br /> Title: <br /> Signed XSide)' <br /> r . <br /> u (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I r1 _ ok Date�~ _ <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection <br /> Kase I F' Ins ection <br /> Date - <br /> Dte Inspection By f P' <br /> inspection By z Y ' <br /> Fee IS Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receiv REMIT <br /> d Fly uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> { BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> r a <br /> FEE QjL <br /> r <br /> LESS <br /> PRORATION <br /> ( PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t w►=+- <br /> Received by - <br /> '� Date Receipt No. Permit No, I suan a Date Mailed Delivered <br /> 1601 E.HAZELTON AYE.,P.O.Box 2009 STOCKTON,CA:952011 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES R - <br />