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Applications Will Be Processed When Submitted Properly Completed. <br /> �l <br /> APPLICATION <br /> M <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WEAL <br /> ENVIRONMENTAL HEALTH PERMIT v' <br /> WATER QUALITY <br /> ATE) <br /> hereby madeto the San Joaquin Local Health District a permit to construct and/or install thew ork herein described.This application is J <br /> Application is he Y <br /> made in compliance witht'an Joaquin County Ordinance No.1862 and the rules and regulati City/Town San Joaquin Local Health District, <br /> Exact Site Address ' <br /> Phone <br /> Owner's Name City <br /> Address License# Business one <br /> Contractor's Name Emergency Phone <br /> Contractor's Address HD? Yes No <br /> Is Certificate of Workman's Compensation Insurance on File 13 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑With SRECONDITION 13DESTRUCTION❑ <br />�. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER ❑ PUMP rINSTALLATION,9 PUMP REPAIR <br /> REPLACEMENT❑ Q <br /> rU Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit �– Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line— Private Domestic Well �_-f�— <br /> TYPE OF WELL <br /> INTENDED USE Dia. of Well Excavation <br /> ❑ INDUSTRIAL 11 CABLE TOOL <br /> Ig DRILLED pia. of Well Casing Gf4gs �o r1 �C <br /> DOMESTIC/PRIVATE El DRILLED <br /> Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC <br /> � 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Te of Grout <br /> i <br /> El CATHODIC PROTECTION ;R ROTARY Type S <br /> ❑ OTHER Other Information C <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL K ry- <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump " � <br /> r PUMP REPLACEMENT: <br /> ❑ State Work Done y <br /> PUMP REPAIR: ❑ State Work Done Approximate Depth <br /> DESTRUCTION OF WELL: 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 /> Home owner or licensed agent's signature cert+ties 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 per of the work for which this <br /> loy persons subject to workman's compensation laws of California." <br /> permit is issued, 1 shall emp <br /> i <br /> I wil all for a Grout spectioY prior to grouting and a final inspection. r <br /> y <br /> Title: Date: <br /> Signed X (Draw Plot'Plan on Reverse Side) <br /> FO DEPARTMENT USE ONLY <br /> PH1 <br /> I Q G Date �a179' <br /> ASE <br /> I Application Accepted By <br /> Additional Comments: hase III Final Inspection <br /> Phase II Grout Inspection Date <br /> Date inspection Sym - <br /> Inspection By /v1 <br /> I PER UNIT � PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> Q <br /> FEE p 5 <br /> ,3 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHERS <br /> � --4—per it No.. Issuance Date ,- Mailetl Delivered <br /> - D e Receipt No. __ •"� '` STOCKTON,CA 95201 �F <br /> . Receive y 6R1 E.HAZELTON'AVE.,P.O.Box-2009 <br /> APPLICANT—RETLIRN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES �� — <br />