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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign Th'Application. UUFOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,'Suspendable) PUMP& I~LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY tzp U. <br /> AL <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thework herein described-T.hisap Ica ��s <br /> made in compliance with San J a in Co my O inane No. 1862 and the rules and reg y lat16ns of the San,oaquuin Local I-jeallh District. <br /> a E City/Town , <br /> Exact Site Address -73 <br /> :,ST V Phone / JJ <br /> Owner's Name , r f� City, <br /> Address - Business Phong <br /> License# Q— :3 t <br /> Contractor's Name I f�,� 5 `Emergency Phone m <br /> Contractor's Address �� No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK}: NEW WELL❑ DEEPEN ❑ RECONDITION❑ '� DESTRUCTION❑ <br /> WELL CHLORINATION 13WELL ABANDONMENT ❑ £ OTHER 11PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> REPLACEMENT19,_ Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit 'Other <br /> Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL`, ❑ CABLE TOOL Dia. of Well Excavation <br /> El DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE "' - � Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC 11 DRIVEN <br /> ❑ IRRIGATION +F ❑ GRAVEL PACK Depth of Grout.Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ {T <br /> ElOTHER Other Information <br /> El DISPOSAL <br /> ❑ GEOPHYSICAL Surface-Seai Installed By: 1 <br /> PUMP INSTALLATION: Contractor <br /> H.P. ,,n <br /> Type of Pump 1 110, V <br /> PUMP REPLACEMENT: R State Work Done <br /> PUMP REPAIR: 13 State Work Don <br /> e (n <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: . . , <br /> Y.` <br /> Describe Material and Procedure <br /> k <br /> ' I hereby certify that I have prepared this application and that the work,wifl 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 certifies the following:"I certify that in the performance of the work for which this perm't <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California'' <br /> certifies the following."I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Gr u I s ction prior to grouting and a final in pe. <br /> Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHA11 13IN <br /> SE 1 4 J\,q�pV Q� Dated—_ <br /> Application Accepted 8y <br /> Additional Comments: <br /> Ph s III Final Inspection <br /> Phase 11 Grout inspection Date a <br /> Inspection <br /> 'Date Inspection B.y <br /> By <br /> Fee is Due: 11ANNUALLY ❑ PER UNIT t ❑ PER SITE © EACH ❑ January 1 &Received 13y January 31 July 1 &Re eiV REMIITBy uIy 31 <br /> f 'BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 6 4 L /SEL T1 <br /> PENALTY <br /> OTHER <br /> OTHER •r - - <br /> 7 V <br /> - to - Receipt No. - Permit No. _ - <br /> Iss an a Date Mailed Deli eredM1° <br /> • Received by 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 952- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />