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I Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheAppucauon. <br /> FOR`OFFICE-USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> k ENVIRONMENTAL HEALTH-PERMIT <br /> (COMPLETE IN TRIPLICATE) l}_ s� . WATER. <br /> _ . QUALITY , _ . R <br /> Application isi hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Jo quiff ounty Ordinanc No. 18fi2 and r les and regulations of the San Joaquin Local Health District. <br /> Exact Site Addyress City/Town - <br /> ` r Phane <br /> Owner's Name , - , I ■ ` ' <br /> Address I' p City <br /> License# 'I Business Phone_ <br /> Contractor's Name L. <br /> 3 Emergency Phone } <br /> Contractor's Address -' <br /> Is Certificate l�of.Workman's Compensatiy1rance on File WithSJLHD? Yes NoTYPE OF WORK (CHECK): NEW WEDEEPEN ❑ RECONDITION❑' DESTRUCTION❑WELL CHLORINATION ❑ WELL ONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR VVV111 <br /> REPLACEMENT❑ <br /> DISTANCETIO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL x <br /> r ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL r .P ; <br /> DOMESTiIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I 4 ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC _ O / E <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout . - <br /> ❑ DISPOSAL ❑ OTHER Other-Information <br /> ❑ GEOPHY4SICAL Surface.Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> I Type of Pump P <br /> j = <br /> PUMP REPLACEMENT: 11 State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTlON.OF WELL: Well Diameter, _ Approximate Depth <br /> l'I Describe Material and Procedure <br /> II 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> III issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> I <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I <br /> I will c II for a Grout pect on prior to grouting and a final inspection. <br /> I <br /> Title: Date: <br /> Signed X ai �T.H- - , <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY. <br /> PHASE I Yn P, bate ~ <br /> Application Accepted By <br /> r <br /> 'Additional Commen <br /> k h I r ut Inspection <br /> e Phase III Final Inspection <br /> t Inspection By DatInspection By Date `. <br /> Fee I Due: CYAN UALLY ❑ PER UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> EXPLANATION - ILLING REMITTANCE �/ $ AMOUNT DUE CHECKED <br /> BASE <br /> ATE DAT EMITTED AMOUNT <br /> FEE I'I L4 :3 111 <br /> RATION / <br /> r <br /> —PROPLUS <br /> PENALTY ! <br /> OTHER l <br /> OTHER <br /> J / - <br /> Received by pate <br /> Receipt No. Permit No. u - I suanc Date Mailed '=Delivered <br /> - - _ - _ <br /> 1601 E.HAZELTON AVE,,P.O.Boa 2009 "STOCKTON,GA 95291 <br /> - <br /> P <br /> PEICANT—RETURN ALL COPIES ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> .,A 4 <br />