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...... <br /> Applications Will Be Processed When Submitted Properly omp e e �. <br /> .F_Ofi OFFICE USE: <br /> APPLICATION '° <br /> ' - (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �o j _ WATER QUALITY L �3 <br /> (COMPLETE IN TRIPLICATE ✓� "�"'€ <br /> a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District for <br /> made in compliance with.San Joaquin County Ordinance No.186 and th ruffles and regulati�an�sy f tl]enSap,Joagn Local Health District. <br /> Exact Site Address <br /> oL Phone e # <br /> Owner's Name City— <br /> Address <br /> ity <br /> Address t .2 <br /> License�Z-�J�--•-� Business Phone . <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes E G I <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN.. <br /> DEEPEN . RECONDITION 13❑ DESTRUCTION[] <br /> WELL CHLORINATION 11WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ I <br /> REPLACEMENT❑ ts 1 <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank' �� Other S <br /> Sewage Disposal Field,�/)�._ 1 Cesspool/S(epage Pit <br /> Property Line/� Private Domestic Well _. � - Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 13INDUSTRIAL CABLE TOOL Dia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE DRILLED Dia. of Well Casing i <br /> 1:1 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> A IRRIGATION I <br /> 13 ROTARY Type of Grout <br /> 13 CATHODIC PROTECTION <br /> ❑ DISPOSAL OTHER❑ OTHER Other Information _. <br /> k Surface Seal Installed By: <br /> ❑ GEOPHYSICAL J� <br /> PUMP_INSTALLATJON: Contractor <br /> H.P. <br /> Type of Pump <br /> 1 PUMP�zTiEPL'ACEMENT: <br /> 13.State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Ir -Describe Material and Procedure <br /> k _ �: <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin oun y <br /> ordinances, state laws, and rues 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-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall emplo persons/object to workman's compensation laws of California." <br /> I will all for a Grou Rspe i n P Ar 5 grouting and a final inspection. .0 <br /> f Date: <br /> I Signed X Title: <br /> (Draw Plot Plan on Rever Side) <br /> FOR D PARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> �as al Ins ection <br /> � '�Ir/ <br /> Phase It Grout Inspection pate <br /> p ,Inspection By <br /> Date Inspection By <br /> ❑ ER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedByJuly 31 <br /> Fee IS DUe: ❑ ANNUALLY PER UNIT El P <br /> BILLING REMITTANCE $ AMOUNT DUE CHE <br /> r BASE EXPLANATION DATE DATE REMITTED AM <br /> I <br /> FEE i <br /> LESS <br /> k PRORATION <br /> g PLUS <br /> F PENALTY <br /> OTHER -- <br /> OTHER t - <br /> -71(19 <br /> Issu nce Date Mailed Delivered <br /> Receipt No. Permit No <br /> Date - - <br /> Received by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> ,. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL KEALTH PERMITISERVICES <br />