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` Applications Will Be Processed When Submitted Properly Completed. Be SureToSign <br /> FOR OFFICE use: ` APPLICATION <br /> CD �� (For Non-Transferable, Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY .. . rf ,. ,. 4, q .. I=t�;...r. <br /> (COMPLETE IN TRIPLICATE) .,is. <br /> c �+ <br /> Application is hereby madetathe San Joaquin Local <br /> OrdinanHealth <br /> ce N ISi8fi2 andthe rutles and regulatdions of the S n Joaquin)Local HeathTDistrriiicp'tcation is <br /> made In compliance with San Joaquin,Count -. • . -A-A -W, "--I"- <br /> V t- ��'� f y City/Town <br /> , ` ] <br /> Exact Sit:e. 7✓Address ,-„ � J� 117 <br /> Phone w <br /> Owner's Name City fir° <br /> Address F* 7_1 �. r License# f ►�Business Phone <br /> Contractor's NameEmergency <br /> Phone` �` • _ <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With IWith LHD? Yes O STRUGTION❑ <br /> YP _ w <br /> TE OF WORK (CHECK) NEW WELL❑ DEEPEN 1 <br /> - WELL ABT© <br /> ANDONMENOTHER ❑ PUMP INSTALLATION® PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ <br /> REPLACEMENT❑ Pit Privy V” <br /> Sewer Lines , I <br /> DISTANCE TO NEAREST: Septic Tank ;Cesspool/Seepage-Pit - -Other <br /> Sewage Disposal Field Public Domestics Well <br /> Property Line Private Domestic Well. <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL - <br /> 13 CABLE TOOL Dia. of Well Excavation <br /> E Dia. of Well Casing <br /> DOMESTIC/PRIVATEl 11DRILLED s= <br /> ,y. 11 DRIVEN Gauge of Casing, <br /> ❑ DOMESTIC/PUBLIC _ -_j., _ y Depth of Grout Seal <br /> ❑ IRRIGATION <br /> 13 GRAVEL PACK <br /> ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION Other Information <br /> ❑ DISPOSAL. j " ❑ OTHER <br /> Surface Seal lnstaNe 8y: <br /> ❑ GEOPHYSICAL - Ij <br /> j PUMP INSTALLATION: Contractor , H.P.Y Type of PumP. E <br /> PUMP-REPLACEMENT: <br /> C1 State Work Done ` �- � % <br /> F PUMP Rte: State Work Done <br /> Ajiproximale Depth <br /> ' DESTRUCTION OF WELL: Well Diameter <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 /> Home owner or licensed agent's signature certifies the following:"I certify that 0 the orkfnperformance' ompo satin forwhof Cali permit <br /> is issued,`I shall not employ any person in such manner as to become subject <br /> '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 /> jper-mit is issued, I shall employ persons subject to workman's compensation laws of Ca lifornia." <br /> 1 -t- <br /> R ; I wi call for a'Grout Inspec ion prior routing and a final inspection. <br /> J y <br /> XI <br /> itle: t- Date:_. QI <br /> Signed wu♦� (prow Plon on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I pate <br /> Application Accepted By <br /> Additional Comments. w hasp ll i Inspection �� <br /> a,Phase 11 rout Inspection , <br /> pate Inspection By <br /> Inspection By t <br /> i <br /> k Fee.IS Due: ❑ ANNUALLY ❑ PER UNIT` ❑ PER SITE C1 EACH' ❑ January I &Received By January 31 - ❑ July t &ReceiveddEB'ylJuly 31 <br /> g _ BILLING - REMITTANCE,- $ - AMOUNT DUE CHECKED <br /> k _ <br /> BASE" EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE; - <br /> LESS 'T A <br /> PRORATION - - <br /> PLUS <br /> PENALTY I <br /> OTHER <br /> k <br /> I OTHER <br /> Re ' - <br /> Permit No- I uanc Date Mal$ed <br /> ebived by Date Receipt No. Delivered <br /> 1601 E.HAZEAVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES a {. <br />