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pp� � *' ) 1 It t <br /> ic�ltons��ifliBe rc�cessad�A1�ien SuAPPLICATIONpleied. Be Sure oSign <br /> FOR OFFICE USE: <br /> X4 .. ' 182(For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> !ZAN JOA aN LOCAL WAFER QUALITY <br /> (COMPLETE IN TRIPLICAlE)� g <br /> Application is N TRI LICAmade t oa I b a althDistrictforapermittoconstructand/orinstalithework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No- 1862 and the rules and regulations of the San Joaquin Local Healt District. <br /> � �" Al, 5 �1/1.S d" City/Town <br /> Exact Site Address WO r <br /> E Phone /— �"/� i <br /> Owner's NameCity oc,K <br /> Address <br /> /)-1✓icense Business Phone � <br /> Contractor's Name <br /> Contractor's Address o +L Emergency Phone` <br /> Na <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? I Yes STRUGTION❑ <br /> TYPE OF WORK (CHECK): NEW WELLY DEEP � <br /> WELL CHLORINATION ElWELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION PUMP REPAIR .- <br /> REPLACEMENT❑ ��/ /' Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines e <br /> tit Sewage Disposal Field_ �'f f" Cesspool/Seepage Pit /0a Other <br /> f- Public Domestic Well <br /> ( Property Line�� l Private Domestic Wely.� . <br /> INTENDED USE `' ❑ CABLE TOOL TYPE OF WELL <br /> Dia. of Well Excavation <br /> ❑ INDUSTRIAL f <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing rA <br /> f <br /> ❑ DOMESTIC/PUBLIC `s!❑ DRIVEN Gauge of Casing 0 VG <br /> , <br /> ❑ IRRIGATION ORGRAVEL PACK Depth of Grout Seal 7� <br /> 1-1 CATHODIC PROTECTION ROTARY w <br /> Type of Grout i° nlT <br /> ❑ DISPOSAL <br /> C1 OTHER Other Information <br /> " i ;Surface Seal Installed By: <br /> ❑ GEOPHYSICAL 4 <br /> PUMP INSTALLATION: Contractor <br /> N.P. 1^ <br /> Type of Pump "�- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> I` rt Well Diameter FAQproximate Depth <br /> DESTRUCTION OF•WELL: 4 I , r <br /> L____I'_��Describe 1mater!al and Procedure <br /> I hereby certify that I have pi p ed�this application and that the work will be done in accordarice with San Joaquin County <br /> ordinances, state laws, and rules and egu1atib ns of the San Joaquin Local Health District. ;�!F ➢ <br /> Home owner or licensed agelrt's�signatyre�certifies thelollowing:"1 certify that in the performance of theworkforwhichihispermit <br /> is issued, I shall not employ any person in such.manner as to become subject to workman's compensation laws of California.'.' <br /> I Contractor's hiring or subcontracting signature eerlifies 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 w <br /> . I — r <br /> I will call r a Grout In ction prior to grouting and a final <br /> • � <br /> inspectlo <br /> Title: s Date: <br /> Signe vrse Side) _ <br /> r Q FOR DEPARTMENT USE ONLY <br /> PHASE I .� -.+�-.,�.- `. <br /> QL Date <br /> Application Accepted By <br /> Additional Comments: - <br /> Phase II Grout Inspection / Pha a III Final Inspection�� <br /> �7aei ( ��� Inspection B� Date <br /> PrY> - � <br /> Y=`� ^— <br /> Inspection B %� <br /> Date_ ��� <br /> , <br /> G {'Fee IS DUBT'0-ANNUAL`LY""'0 PER UNIT ID-PE - .❑'EACH " ❑ January-1 &Received ByJanuary-3 - --0 July 1 &-Receiv July 31 <br /> REMIT <br /> '-^ <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE 4i EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> I <br /> OTHER <br /> Date Receipt No. Permit No. - a. _-_Is uan. Date Mailed Delivered <br /> Received by - '"` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH,PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />