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..% - rr <br /> v.k pppiications Will Be Processed When Submitted Properly Completed. Be Sure o +g l7dJ <br /> APPLICATION <br /> FOR OFFICE USE: <br /> -� -, <br /> (For Non-Transierable, Revocable,Suspendabie) PUMP &WELL <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY ,< <br /> (COMPLETE IN TRIPLICATE) <br /> Local Health District fora permitto construct and/or install the work herein described.This application is <br /> Application is hereby made tothe San Joaquin ! <br /> n Local Health District. <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the mules and regulations of the San JoagV� <br /> Exact Site Address <br /> ac 7 City/Town <br /> �+-- Phone <br /> Owner's Name City 4�__r <br /> Address Business Phone ` } <br /> License # <br /> Contractor's Name Emergency Phone "..2Contractor's Address No i' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes <br /> TYPE OF WORK (CHECK): NEW WELL�DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> ❑ O, <br /> WELL ABANDONMENT 13 OTHER PUMP INSTALLATION M-----PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ <br /> REPLACEMENT r y—Sewer Lines Pit Privy <br /> -x� �— <br /> DISTANCE TO NEAREST: Septic Tank � 2 Cesspool/Seepage Pit ;/l�'� Other y <br /> [� <br /> Sewage Disposal.Field 1 <br /> Property Lined d Private Domestic Well �D 4— Public Domestic Well <br /> INTENDED USE TYPE OF WELL t, ',e <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I'1 IND STRIAL RIVATE ❑ DRILLED f Dia. of Well Casing <br />` Gauge of Casing <br /> ElDOMESTIC/PUBLIC ❑ DRIVEN - ' <br /> I 13IRRIGATION ❑ GRAVEL PACK Depth Grout Seal <br /> 11 CATHODIC PROTECTION NARY Type off Grout <br /> 13 DISPOSAL <br /> El OTHER Other Information <br /> Surface Seal installed By: r s <br /> ❑ GEOPHYSICAL , <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: _ ❑ State Work Done a <br /> PUMP REPAIR: ❑ State Work Done -Ile <br /> Well Diameter 60 Approximate Depth <br /> DESTRUCTION OF WELL: 'Z7 <br /> + <br /> Describe Material and Procedure <br /> ccordance with San Joaquin County <br /> I hereby certify that I have prepared this ap ication and that the work will be done in a <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 for which 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:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and final inspection. <br /> plJf2 Title: Date: <br /> l Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> 1 <br /> FOR DEPARTMENT USE ONLYF <br /> k <br /> ���yPHASE 1 DateZ/ � <br /> Application Accepted By <br /> Additional Comments: <br /> Phase III Final Inspection <br /> Phase 11 Grout Inspection _ Date <br /> Inspection Bye Date Inspection By <br /> ❑ PER SITE �❑ EACH ❑ January 1 &Received By January 31 ! ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT REMIT <br /> 1 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> Q o, r G <br /> FEE L . r <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> } Per'mi1�N�e. Issuance Date Mailed Oe�redf/ <br /> Received by Date Receipt No. <br /> 1601 E.HA2ELTON AVE,,P.O.Box 2009 STOCKTON,CA 95 <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> � <br />