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• Applications Will Be Processed When Submitted rop <br /> FOR OFFICE USE: <br /> i APPLICATION <br /> (For Nan-Transferable, Revocable, Suspendable) pUMP&WELL I <br /> ENVIRONMENTAL HEALTH PERMIT <br /> m WATER QUALITY 1 <br /> (COMPLETE IN TRIPLICATE) construct <br /> Application is,hereby made tothe San Joaquik Lp°allnancehN11 os1862 andtrict for a p he rulos and regulations oftthe Sa oroah ur nl Local Heath District.application is <br /> made in compliance with San JoaIquin Coin o City/Town ' <br /> t Site Address Exact 6 <br /> Phone d �6 <br /> RS Q <br /> Owner's Name City - q <br /> ill 2_ <br /> Address �� License# 3g 15y� Business Phone <br /> Y <br /> Contractor's Name Z , Emergency Phone V <br /> Contractor's Address No W <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW W AB�ABANDONMENT OTHER RECONDITION <br /> ❑ ITI P ❑P INSTALLATION 13DESTRUCTIONO PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL <br /> REPLACEMENT❑ 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 <br /> 1111 TYPE OF WELL � slJ� - � <br /> INTENDED USE �� /O" 't. ka.Ai <br /> CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing <br /> 9K !D <br /> ,DOMESTIC/PR[VATE �❑ DRILLED El DRIVEN <br /> Gauge of Casing , <br /> t ❑ DOMESTIC/PUBLIC Depth of Grout Seal 6V <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> t 13ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION Other Information <br /> . <br /> 11 DISPOSAL <br /> 11 OTHER <br /> � Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor d <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> s rfi/eYreby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> t <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> ce of the work Home owner licensed agent's signature <br /> following:as to become subject to workman's compensay that in the performan tion�aws of CaliforrwhIich this nia." <br /> ` <br /> �0 is issued, I shall not employ any person in such manner <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that laws of f California." <br /> the performance of the work forwhich this <br /> permit is issued, 1 shall employ persons subject to workman's compensation <br /> �1211 all r a Grout Ins ection prior to grouting and a final inspection. 2 Z fq?� <br /> Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE I `-�"`�'CJ�.+ Date <br /> l Application Accep / <br /> Additional Commeph s II Final Irfspeclion ��v <br /> { .+Sspection � /&P� Date <br /> Inspection 13y59;1 <br /> Date G Inspection By <br /> " 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 $ AMOUNT DUE CHECKED <br /> BASE"Iii EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE x <br /> LESS <br /> PRORAT40N <br /> `PLUS <br /> PENALTY <br /> -i <br /> OTHER if <br /> OTHER <br /> Receipt No. Perini[No. Issuance Date Mailed Delivered <br /> Received by "q Date - 1601 E.HAXELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES s <br />