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App I tons Will Be Processed Wh bmitted Properly Completed, Be Sure aSign e <br /> FOR OFFICE USE: AUG 16 1982 APPLICATION <br /> (For Non-Transterable,Ret c ble, Suspendable) PUMP&WELL <br /> SAN eOAf UIN 9"bNMENTAL HEALTH PERMIT <br /> HEALM DISTRICT WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone` 47r—7-77 ` <br /> Owner's Name City- <br /> Address <br /> ity y <br /> Addressti ,.a <br /> License#�7 -Business.Phone'A;1 <br /> Contractor's Name _ <br /> PhO = <br /> y Emergency, 'one`" <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation insurance� DESTRUCTION❑ <br /> on File With SJLHD? Yes_ _ _ <br /> F TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ Y' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT © OTHER ❑ PUMP INSTALLATION a-- PUMP REPAIR❑ <br /> REPLACEMENT❑ �.i Pit Priv 4 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> - Sewage Disposal Field <br /> Cesspool/Seepage Pit ;Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE <br /> r 13❑�,,,, IN4 CABLE TOOL Dia. of Well Excavation <br /> LB'��RUSTRIAt DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION t ❑ GRAVEL PACK Depth of Grout Seal <br /> I ❑ ROTARY Type of Grout " <br /> El CATHODIC PROTECTION { j <br /> ❑ ❑ OTHER Other information <br /> DISPOSAL <br /> ❑ GEOPHYSICAL Surface Seal.installed By: k <br /> PUMP INSTALLATION: Contractor <br /> TType of Pum H.P. <br /> Yp p— <br /> PUMP REPLACEMENT: ❑ State Work Done ry .-�- <br /> PUMP REPAIR: ❑ State Work Done j <br /> i Well Diamete - " - Approximate Depth <br /> DESTRUCTION OF WELL: ra <br /> Describe Material and Procedure i <br /> Thereby certify that Ihave 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. t <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> s compensation laws of California." <br /> is issued, I shall not employ any person in such manner as to become subject to workman' <br /> Contractor's hiring or sub-contracting 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 workman's compensation laws of California." t <br /> � i <br /> I will call for Grout Inspection prior to grouting and a final inspection. <br /> Signed XPlTitle: _ <br /> Date: E �� <br /> c;. i (Draw Plot an on Reverse Side) <br /> --------------------- <br /> FOR DEPARTMENT USE ONLY <br /> PHASEII <br /> t � Date <br /> Application Accepted By <br /> Additional Comments: _ se III Finnspeclion <br /> Phase it Grout Inspection <br /> Inspection By Date <br /> Inspection By Date 3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8,'Received By January 31 ❑ July 1 &Received By July 31 <br /> RE <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE _ DATE REMITTED -- AMOUNT <br /> O <br /> FEE <br /> LESS Z <br /> PRORATION <br /> PLUS <br /> [- PENALTY. „r <br /> OTHER <br /> OTHER _ <br /> 2� 2� <br /> Delivered - <br /> Received by Date <br /> ' �Receipt No. a Permit No. - 1 suance D e Mailed - . - <br /> 1601 E.HAZ.ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />