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I It , 4 PJiceJedZn Submitted ProperlyCompleted. Be Sure 1o bign IneApplleatwII• <br /> FOR OFFICE USE: --re APPLICATION <br /> MAY 14 1980`F -Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> k ,JOA, 'UIN MCAL WATER QUALITY <br /> I' (COMPLETE IN TRIPLIC _ <br /> (COMApplicationisNTRI madet� 4aTbiaWiSTR�ealthDistrictforapermittoconstructand/or instal I the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San ,,JAaquin Local Health District. <br /> Exact Site Address —RdE City/Town <br /> I Phone &.. <br /> Owner's Name <br /> Address City_ La's _ <br /> Contractor's Name e- License# Business Phone <br /> Contractor's Address Emergency Phone} <br /> ryn <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT E] OTHER 11 PUMP INSTALLATION 5r PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy y \A <br /> r: Sewage Disposal Field, Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ` IR IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 7�Di <br /> Type of Pump H.P. <br /> t <br /> PUMP REPLACEMENT: ❑ State Work Done t <br /> PUMP REPAIR: ❑ State Work Done c <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> s <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 for which this permit <br /> is issued, l 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will aN for a Grout l ection rior to grouting and a final inspectio <br /> Signed X Title: Date: <br /> (Draw Plot Pian on Reverse Side) <br /> t _ <br /> FO DEPARTMENT USE ONLY <br /> PHASE / a <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection ease III Final Inspection <br /> Inspection By Dater Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT LfwER SITE ElEACH ❑ ,January 1 &Received By January 31 ❑ July 1 &Received By July 31 . <br /> REMIT <br /> BASE ;EXLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> ATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY _. <br /> a' OTHER <br /> Y' OTHER - - '^'✓S " <br /> �- <br /> r Received by Date Receipt No. Permit No. Issuance ate Mailed Delivered <br /> 4 APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.'HAZELTON AVE.,P.O:Boa 2009 STOCKTON,CA 95201. <br />