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s Applications Will Be Processed When Submitted i.roperly Completed-.-Be Sure To Sign The Application. <br /> -FOR OFFICE'USE: APPLI�TI ` <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wl h San Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 624 W11COX <br /> kd. City/Town Stockton <br /> Owner's Name Larry H. M0011,1016 Phone 931.-3210 <br /> Address 4943 errvlane�n,;ro City Skn. <br /> Contractor's Name Monrmant c WiatLicense# 267_696Business Phone same as above <br /> Contractor's Address ' and Emergency Phone same <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br />€ WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ 6% <br /> REPLACEMENT❑ <br />' DISTANCE TO NEAREST: Septic Tank / Sewer Lines Pit Priv r� <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> k Property Line Private Domestic Well Public Domestic Well <br /> t <br /> MENDED USE TYPE OF WELL <br /> i (INDUSTRIAL 0,�,,�CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE L5DRILLED Dia. of Well Casing / �G <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ,❑,.,,., GGR/RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION IrrFiOTARY Type of Grout <br /> ❑ DISPOSAL ❑ 97-HER Other Information <br /> ❑ GEOPHYSICAL Surface Peal Instal d 5,v: <br /> PUMP INSTALLATION: Contractore9 <br /> Type of Pump �a H <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <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 /> 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 /> I permit is issued, I shall employ.persons subject to workman's compensation laws of California." <br /> I wi fo Gr on prior to grouting and a final inspection. <br /> I ' <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I ` <br /> Application Accepted By (� y Date <br /> Additional Comments: <br /> Phase II Grout Inspection �h a III F'naI Inspection _ <br /> Inspection By Date Inspection By r, M W Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I i BILLING REMITTANCE $ REMIT <br /> BASE EXPLANAT40N AMOUNT DUE CHECKED <br /> DATE DATE MITTEO AMOUNT <br /> k <br /> ` FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by -Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 3 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITYSERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 - STOCKTON,CA 95201 <br />