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.f Appli at'h ill(( af1xoe�ss' ' Tien Su ' I1ted Properly Completed. Be SureToSignTheApplication. VN <br /> �!� � ` �' PPLICATION <br /> FOR OFFICE USE: : <br /> II! ( r Non- terable, Revocable,Suspendable) PUMP&WELL r <br /> AUG 20 , - <br /> I� IRONMENTAL HEALTH PERMIT <br /> COMPLETE IN'TRIPLICATE I ,'1;.. LF ,WATER QUALITY <br /> ( ) 5 , Q i LOCAL Q <br /> Application is hereby made to the S" "strictfora rm' to cknruct and/or installt�hework ei described.Th'sapplicationis <br /> made in compliance w' S Jo Coun r inance N 862 a r I s regulations of the San ca 4 <br /> Exact Site Address City/Town <br /> Owner's Nara �' Phorie" <br /> Address <br /> City. t. <br /> Contractor's Name r a > ense# Busll�s`s Phone' <br /> Contractor's Address - ergen&jftone - <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> WE <br /> �y _ . ., <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN.❑ RECONDITION❑ _ DESTRUCTION❑ T <br /> WELL CHLORINATION-13 WELL;ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ r <br /> REPLACEMENT 00 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lihe Private Domestic Well Public Domestic Well , <br /> INTENDED USE ---•TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation -� 11 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing \\\ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION I ❑ GRAVEL PACK Depth of Grout'Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type'of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT:: O'State Work DoAo��� <br /> PUMP REPAIR: 13State Work Do <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that I have prepared this application and that the work will be done i6'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, I shall n toy a`ny person in such manner as to become subject to workman's compensation laws of California." <br /> Contracto' trig rsub-contra ignature certifies the following:"I c I that in the performance of the work for which this <br /> permi Is i ue shall a play persons subject to workman's campen t' n laws of California." <br /> I we call I pectio p 'or rout' nd a final inspecti <br /> Signed X <br /> Title: -Date: 9 L7 <br /> �I $ (Draw Plot Plan owlieverse Side) <br /> E _ ' <br /> _t. 4 ` ' FOR DEPARTMENT USE ONLY I j <br /> PHASE I r� -- Date + <br /> Application Accepted By <br /> Additional Comments., <br /> ' Phase II Grout Inspection ase Ill F tion <br /> Inspection•By - �� Date - Inspection B ate <br /> E Fee IS Due: ❑ ANNUALLY ❑,P I�R UNIT` ❑ PER SITE ❑ EACH. ❑ Janua &Received B nuary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> - � ANATION BILLING +., - `REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPi_ <br /> - <br /> DATE DATE REMITTED, AMOUNT <br /> FEE ( . <br /> LESS Y r <br /> PRORATIONi <br /> PLUS } <br /> PENALTY <br /> �. OTHER - <br /> OTHER <br /> Received by- Date 1I. -Receipt No. — � —W. - Permit No. 'Issuance a e-- — -Mailed -Delivered <br /> 1601 E.HAZELTON AVE.,P.O.60:2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO:;1 ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />