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Applications Will Be Processed When Submitted Proper y F <br /> APPLICATION _ <br /> �01-A— ;USE: (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r_ �5- 3 _ 030 -[Z 6 <br /> WATER QUALITY application is } <br /> (COMPLETE IN TRIPLICATE) �o ° "� <br /> No. 1882 and the rules and regulations of the San Joaquin Local Health D'+strict. <br /> A lication ishereby,mac�etatheSanJoaquinLocalHealthDistrlctforapermittoconstructandJorinstalltheworkhereindescribe Is <br /> �* <br /> made in compliance with San Joa in Gount Ordinance� 5 CafoD�acf-City/Town i <br /> Exact Site Address s �� -- � phone G�1 <br /> Owner's Name City <br /> Address V�9 icense# Business Phone { <br /> Contractor's Name H� Emergency Phone <br /> No '_ <br /> Contractor's Address _ -h <br /> Is Certificate of Workman's Compensation on File With SRE ONDITION❑ DESTRUCTION❑ <br /> f TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN <br /> l WELL CHLORINATION ❑ <br /> WE!,L ABANDONMENT El OTHER 13PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT 13 � Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> I Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> p Property Line Private Domestic Well <br /> 4 I TYPE OF WELL <br /> INTENDED USE Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> 11 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE 13 DRIVEN Gauge of Casing <br /> ❑ OMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> 1�.7 IRRIGATION 13 ROTARY Type of Grout i <br /> { <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor H.P. <br /> PUMP INSTALLATION: Type of PUMP <br /> ❑ State Work Done <br /> • PUMP REPLACEMENT: El <br /> State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: <br /> 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 /> r or licensed agent's signature certifies the follow "1 ing: certify that in the performf tal <br /> ance of the work forwhopermit <br /> i isuch manner as to become subject to workman's compensation <br /> is issued, l shall not employ any person n laws of California." <br /> Home owne <br /> l orsub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> Contractor's <br /> E permit is u I shall emplo sons subject to workman's compensation laws of California." <br /> I will or a Grout ins n pri o grouting nd a final inspec'on. y� <br /> Date: <br /> i Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> ( FOR DEPARTMENT USE ONLY <br /> t <br /> PHASEI Date <br /> Application Accepted By <br /> Additional Comments: 1 Phase ill Final Inspection <br /> Phase If Grout inspection 1 Oln ection By Date <br /> • <br /> Inspection By Date <br /> IE C � January 1 &Received By January 31 C] July 1 8 Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE REMIT <br /> REMITTANCE AMOUNT DUE CHECKED <br /> BOLL REMITTED <br /> �� BASE AMOUNT <br /> ( EXPLANATION D DATE <br /> . FEE F;;� <br /> LESS <br /> 1 PRORATION n <br /> PLUS �I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No. Permit No. <br /> Issuance Date Mailed Delivered <br /> Received 6y Date 1601 E.HAZELTON AVE,,P.D.Boz20D9 "STOCKTON,CA 95201 <br /> APPLICANT—'RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITtSERYICES <br />