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p a#ionl rill!BelProcess en Submitted Properly Completed. Be Sure To Sign The Application. <br /> ff7l <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> a s0§K6IRONMENTAL HEALTH PERMIT <br /> (COMPLt ; "y�u') WATER QUALITY <br /> Application is hereby madnet� <br /> Y �ut`n Local Health District fora permitt0 construct and/or install thework herein described,This application is <br /> made in compliance with San oaqui ounty Ordina ce No. 1g and the rule a regulations of the Sa Joaquin Local Health Distri t. <br /> Exact Site Address y 09 '8 Q ' <br /> 2ity/Town_ [' <br /> Owner's Name ' <br /> Address Phone Z. <br /> Contractor's Name City <br /> _ ',License# D / <br /> Contractor's Address Business Phone_ P6 t <br /> Emergency Phone,, ►, s., ,, <br /> Is Certificate of Workman's Compensation insurance on Fil With SJLHD? <br /> Yes No <br /> TYPE OF WORK (CHECK): .- NEW WELL �DEEPEN❑'" RECONDITION©DESTRUCTION❑= -_ <br /> WELL CHLORINATION ❑ - WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11y r <br /> REPLACEMENT❑ } PUMP REPAIR 11 + <br /> DISTANCE TO NEAREST: . Septic Tank � ® � Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field... - Cesspool/Seepage Pit <br /> Other. } <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE ( TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOO_L <br /> .. - -- Dia. of Well Excavation_ <br /> DOMESTIC/PRIVATE ❑ DRILLED � Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11 IRRIGATION Gauge of Casing _ /,6 t9&,;i, <br /> GRAVEL PACK Depth of Grout Seal t, ' <br /> 11 CATHODIC PROTECTION K rx(ROTARY <br /> ❑ DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL y <br /> Surface Seal Installed By: d <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump z - H.P. w <br /> PUMP REPLACEMENT: El State Work Done <br /> PUMP REPAIR: ❑'State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth r- <br /> Describe Material and Procedure ' <br /> a I hereby certify that'l have prepared this application and that the work will be done in accordance with San Joaquin County 'f <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 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 performancebf the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." - - <br /> I ill e11 fora Grout Inspec ' prior to grouting and a final inspection. <br /> Signed X 3 Title: Date: `rte <br /> (Dr P of Plan on Revers Side) - - <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I <br /> Application Accepted By `v p <br /> Additional Comments: - - <br /> Date �G 3 <br /> . t <br /> Ph 11 Grout Inspection ' } <br /> �/ P Phase 111'Final I ec ion c <br /> Inspection By �"^" -- _ ! :�%t,. 1 �J <br /> w Date�4 Inspection Date Z, Z. <br /> Fee Is Due: © ANNUALLY ❑ PER UNITr f <br /> ❑ PER SITE F' ❑ EACH ❑ January 1 &Received By January 31 El July 1 &Received By July 31 <br /> - BASEEXPLANATION BELLING REMITTANCEaAH <br /> MIT <br /> $ CKED — <br /> DATE c GATE •'REMITTED <br /> FEE `". - fi UNTLESSPRORATION - - APLUS �PENALTY <br /> OTHERy <br /> ' OTHER <br /> R terve y ate - Receipt No. -• Permit No. __ - ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Mailed Delivered <br /> _ 1601 E,HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ' <br />