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Applicatiorts4WIII Be��4717 <br /> e t u d Properly Completed. Be Sure To Sign The Application. - <br /> FSR oFFlc� use: - 4y LIGATION t <br /> (For Non-Tran ble, Revocable, Suspendable) <br /> SEP I"M6NMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> p.i' L ��tip- <br /> Application is hereby madeto theSan �.,,�1fJin rr T93e11IJl5FNL^L1< a permit to construct and/or install the work herein described.Thisapplicatio is 1 <br /> I�OA \ �L <br /> made in compliance with San Joa .n I� �r �rr'l�JRQ a the rules and regulations of the San a uin Local Wealth District. _ <br /> Exact Site Address City/Town I <br /> Owner's NamePhone qj, <br /> 7 .ir <br /> Address City 14 CaA"Q_40 <br /> Contractor's Name License#� usiness Phone <br /> 7g 1 <br /> Contractor's AddressA4 Emergency Phone I� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No II <br /> TYPE OF WORK (CHECK): NEW WELL. DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ` I <br /> - H � � x W <br /> WELL CHLORINATION.❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATFON PUMP REPAIR❑ <br /> 0 N a ... �,. <br /> REPLACEMENT❑ --- --- --=-I� �„ ��_., �.., . -.. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy jl(P <br /> �t Sewage Disposal FielO Cesspool/Seepage Pit Other <br /> ° Property Line Private Domestic Well Public Domestic Well !( <br /> INTENDED USE TYPE OF WELL I - _ „ ,— -�,� It r. l <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation l <br /> .DOMESTIC/PRIVATE ❑ DRILLED D,ia.of V%I Casing !I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge ofC sia ng 11 <br /> ❑ IRRIGATION .I ❑ GRAVEL PACK Depth of0rout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout t <br /> ❑ DISPOSAL ❑ OTHER Other Information I1 i <br /> ❑ GEOPHYSICAL Surface S al Installed By: <br /> PUMP INSTALLATION: Contractor' 0 4 A <br /> ►. 1 Type of Pump�_ � H.P. <br /> PUMP REPLACEMENT: I ❑ State Work Done II <br /> PUMP REPAIR: ! ❑ State Work Done �{ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth f <br /> f Describe Material and Procedure li <br /> # -1=hereby-certify-that-hhave prepared this-application-and that the work will be done-in-accordance with San Joaquin County <br /> ordinances, state laws, acid 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 for which this permit 1 <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 subcontracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued,`;I.shall employ persons subject to w`orkman's compensation laws of California." <br /> I wit!caY for a Grout`Ins ection prior to grouting and a final lnspectlon. <br /> Signed X .11'4 Title: <br /> t} y ' ; (Draw PIatPlan on Reverse5ide) ' ate: <br /> t FOR DEPAIi7,MENT�IJSE ONLY } <br /> PHASE I <br /> Application Accepted By �' - Date <br /> 1 Adiiitional Comments: ZY ) <br /> Phlase II Grout Ins .ection P s III Fi inspection +y <br /> Inspection BI--aate 9- Inspectio/By 'k Date <br /> � l <br /> :. Fee IS Due: ❑ ANNUALLY ❑° PER UNIT P,ER SITE >❑ EACH ❑ January 1 &Received By January 31 [] July 1 &Received By July 31 <br /> { � ItREMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> } <br /> r SDA`E DATE REMITTED <br /> AMOUNT <br /> FEES". ....« <br /> LESS Ipy 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTWER.. <br /> 9 If� FiER <br /> bail 6 a <br /> Received by DateReceipt No, Permit No. Issuance Date - Mailed Delivered <br />"'� APPLICANT—RETURN ALL COPIES.TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2609 STOCKTON,CA 95201 <br />