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..��.� <br /> *� Applications Will Be Processed When Submitted Properlycompiezea. <br /> APPLICATION <br /> � <br /> USE <br /> � _ : <br /> •--= s, (For Non-Transferable, Revocable, Suspendable) /PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WAVER QUALITY t <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application Is <br /> made in compliance with San Joaquin Co4nty Or finance No.1862 and the rules and regulations of the Joaquin cocas Health District. <br /> Exact Site Address $ t <br /> C Phone 1 <br /> Owner's Name _ City <br /> Address S` - 7 <br /> l � cense#, 9�� Business Phone <br /> Contractor's Name Emergency Phone Ctj <br /> Contractor's Address No j <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes } <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION DESTRUCTION <br /> WELL CHLORINATION 11WELL ABANDONMENT [3OTHER [3 PUMP INSTALLATION C3 PUMP REPAIR❑ <br /> REPLACEMENTt 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 We11 <br /> INTENDED USE TYPE OF WELL_ <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> 13 DOMESTIC/PRIVATE Gauge of Casing <br /> i ❑ DOMESTIC/PUBLIC 11 DRIVEN <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> 11 IRRIGATION <br /> l ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> F Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> ` PUMP INSTALLATION: Contractor G� <br /> H.P. <br /> Type of Pump t�1 ,17 <br /> � . <br /> k PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> � Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this <br /> application <br /> of the San that <br /> the <br /> nwork <br /> will <br /> Heal h one District.in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations <br /> l <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will 11 for a Grout inspection prior-to outing and a final inspect cLn. <br /> Title: . �� Date: <br /> ' Signed X <br /> {Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 - Date <br /> Application Accepted By <br /> 4� <br /> Additional Comments: Ph se I Final inspection <br /> Phase 11 Grout Inspection Date +l - 11 <br /> Inspection By <br /> Date Inspection By <br /> i ❑ Januar I &Received By January 31. ❑ July 1 &Received By July 31 <br /> Fee Is flue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH y REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE �c <br /> ! LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' OTHER G <br /> Date i Receipt No. <br /> Permit No. issuance Date Delivered <br /> Mailed <br /> ., Received by 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 45201 <br /> APPLICANT—RETURN ALL COPIES TO: ENYlRONMENTAL HEALTH PERMITlSERVIGES <br />