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Applications Will Be Processed When SubmittedProperty L:ompleteu. oe 0— •.. n•• •� r <br /> ,,'FICE USE: J APPLICATION <br /> [p <br /> .01? <br /> 0 u?A� (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE YK_t- I w;�WT QUALITY �- 7_ c <br /> �31� �� <br /> Application is hereby made to the San Joaquin Local Health Districtlo a rmitto construct and/or instill thework herein descrl ed.This application is <br /> made in compliance with San Joaquin Cou ty Or inane No. 1862 an the rules and regulations of the San Joaquin Local Health District. <br /> { Exact Site.Address <br /> taD r City/Town <br /> Phone <br /> F ``'Owner's Name t Cit <br /> Address y <br /> License# �3-� Business Phone <br /> Contractor's Name <br /> Emergency Phone <br /> Contractor's Address ` � <br /> N o Q� <br /> Is Certificate of Workman's Compensation Insurance on File With JLHD? Yes — tSy <br /> TYPE OF WORK (CHECK): NEW WELL© DEEPEN-EDRECONDITION 11DESTRUCTION❑ r- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> Sewage Disposal Field_ _ Cesspool/Seepage Pit Other <br /> ' <br /> Property._Line mes <br /> Private Dotic VVell Public Domestic Well , <br /> t INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL x Dia. of Well Excavation , <br /> r` 11DOMESTIC/PRIVATE 13DRILLED _ Dia. of Well Casing <br /> r <br /> i <br /> IRRPUBLIC 1:1 DRIVEN -Gauge of Casing w <br /> IGATION ❑ GRAVEL PACK Depth of Grout Seat <br /> N❑ CATHODIC PROTECTION ❑ ROTARY s Type of Grout <br /> ❑ DISPOSAL ❑ OTHER "Other Information LA <br /> • ❑ GEOPHYSICAL urface Seal Installed <br /> `` Contractor <br /> 4: PUMP INSTALLATION: _�. _ • <br /> Type of Pump H.P. � <br /> } PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: I� State Work Done' <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> t <br /> I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ry <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, 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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i <br /> I f <br /> ill call for a Grout Inspec prior o gr. ting an a final inspecifo. <br /> k <br /> I - Title: Date: <br /> Signed <br /> f (Draw PI Plan on Reverse Side) <br /> I FOR EP TMENT E ONLY <br /> P <br /> HASE ; d <br /> t Dat <br /> on Accepted By <br /> �f r <br /> dditional Comments: I al Inspection <br /> I Phas It rout Inspection ��' <br /> F Date inspection fay .� Date <br /> Inspection By I <br /> S <br /> Fee Is Due: 13ANNUALLY ❑ PER UNIT ❑ PER SITE F-1EACHC3 January 1 &Received By January 3} ❑'July 1 8 Receive EMITuIy 31 <br /> BILLING REMITTANCE $ AMOUNT.DUE CHECKED <br /> BASE. ' EXPLANATION DATE DATE REMITTED i AMOUNT <br /> `FEE # <br /> I LESS - } - <br /> PRORATION - <br /> PLUS ` <br /> PENALTY <br /> OTHER <br /> } OTHER <br /> .S <br /> - . .,,, -PermitNG. - I suance a e Mailed t Delivered <br /> Date, _ Receipt No. <br /> Received by <br /> 1641 E.HAZELTON AVE.,P.O.Box 2009, STOCKTON,CA 95241 <br /> APPLICANT ALL COPIES TO:�ENYIRONMENTAL HEALTH PERMITISERtl10E5 _ <br />