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Applications Will Be Processed When Submitted Properlycompietea. <br /> F08 gFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL - <br /> i ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> in Local Health Districtforapermittoconstructand/orinstallthework herein described.This application is <br /> Application is hereby made to the San Joaqu <br /> made in compliance with San Joa uirlr�oun Ordin nce No. 1862 an the rules and regulatioAW ns of J`�i� Local-Health District. <br /> Exact Site Address {�rr <br /> , Wj <br /> T Phone y�+� <br /> Owner's Name QIRS City <br /> Addressr4�nse Business Phone <br /> . CG JIIt� f� <br /> Contractor's Name <br /> Contractor's Address /9 Emergency Phone <br /> is Certificate of Workman's Compensation insurance on File With SJLHD? Yes NO <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 13RECONDITION ElDESTRUCTION❑ <br /> ❑ PUMP INSTALLATION PUMP REPAIR C) <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Public Domestic Well <br /> Property Line Private Domestic Well 1 <br /> TYPE OF WELL <br /> INTENDED USE a� �Z <br /> IIy CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL w. <br /> 13 DOMESTIC/PRIVATE DRILLED 01a. of Well <br /> ❑ DRIVEN Gauge of Casing F j <br /> 11DOMESTIC/PUBLIC Grout Depth of Seal <br /> �[IRRIGATION ❑ GRAVEL PACKi� <br /> CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> { ❑ DISPOSAL 11 OTHER <br /> Other Information ' <br /> Surface Seal installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> H.P. Q ,. <br /> Type of Pump 0 M ids <br /> If PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter 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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> F <br /> Homeowner 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 /> following:"I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a rout inspection�prr' groutin�and final inspection <br /> Title: Date: <br /> Signed X (Drawlan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY <br /> 6 <br /> I <br /> PHASE 1 ©iI Date <br /> Application Accepted B i. <br /> I <br /> Additional Comments: Phase 111 Final Inspection <br /> se II Grout inspection Date <br /> Inspection By �- <br /> T �. FDate � Inspection By <br /> I °�— # ' <br /> By <br /> l l=ee Is Due' ❑ ANNUALLY ❑ PER UNIT <br /> PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ .1uly 1 &ReceiveRd REMIT 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE' - EXPLANATION DATE DATE REMITTED AMOUNT <br /> F <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS7< 3kf <br /> d ` <br /> PENALTY WW <br /> OTHER <br /> t <br /> OTHER <br /> (,)(7 %J <br /> - Permit No. Issuanc ate Mailed Delivered <br /> Received by Date Receipt No <br /> APPLICANT—RETURN ALL COPIES TON AVE..P.O.Box.2009 STOCKTON,CA 95201 <br /> O: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT <br />