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De OUTV IV <br /> bmitted Properly E;ompieieu. <br /> " Applications Will Be Processed When SuAPPL,CATION <br /> FOR OFFICE USE: ( <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ; <br /> WATER QUALITY a <br /> (COMPLETE IN TRIPLICATE) <br /> inLocalFiealthDistrictforapermittoconstructandlorinstallthework herein described.This application is <br /> Application is herebymadetotheSanJvaqu <br /> No. 1 36hand th �aregulatll of the S Joaquin Local Health District. <br /> made in compliance with San Joaquin County Ordinance <br /> Exact Site Address <br /> { Phone - <br /> Owner's Name Gu _ City <br /> Address G <br /> License Business Pho e ". _ n <br /> --� # <br /> Contractor's Name ' Emergency Phone E <br />} Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLND? Yes_1D <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 0 OTHERRECO <br /> OITI P❑P INSTALLATIONDESTRUCTIO❑❑ PUMP REPAIR❑ �1 <br /> i <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11 <br /> REPLACEMENT❑ / Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank ( ,Sewer Lines <br /> Cesspool/Seepage Pit Other '1 <br /> Sewage Disposal Field <br /> t Property Line Private Domestic We11 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 11 DRILLED Dia. of Well Casing ta. <br /> DOMESTIC/PRIVATE ❑ DRIVEN - Gauge of Casing <br /> Vr-❑ DOMESTIC/PUBLIC Depth of Grout Seal <br /> ❑ IRRIGATION GRAVEL PACK <br /> El CATHODIC PROTECTION 1 ROTARY Type of Grout . / t <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: r' <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> -Type of Pump - <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> well Diameter <br /> Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> p <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." x <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work torwhich this <br /> " permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for Grout I spection prior to grouting and a final inspection. <br /> Title: Date: <br /> ' Signed X <br /> " (Draw Plot.Plan on Reverse Side) <br /> OR PARTME USE ONLY <br /> PHASE 1 J Date <br /> I Application Accepted By <br /> i <br /> Additional Comments. Phase III Final Inspection <br /> 1 Pha a Inspection jf Date <br /> i _ Date r( Inspection By <br /> Inspection By <br /> ❑ ❑ PER UNIT <br /> El SITE ❑ EACH 13 January 1 &Received By January 31 El July 1 R Received <br /> By Juiy 31 <br /> Fee is Due: ANNUALLY <br /> MIT <br /> BILLINGS REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> pt' 4 4 <br /> "F FEE <br /> t LESS <br /> Fl PRORATION <br /> w PLUS <br /> PENALTY <br /> r <br /> a OTHER .r. <br /> I. <br /> OTHER <br /> Delivered <br /> ! <br /> ' Receipt No Permit No Issuance Date Mailed _ <br /> Received by Date <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />