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` Appllaa s} it de o ss vy en fitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: !J `' I PPLl <br /> CATION <br /> (For Non- ferable, Revocable,Suspendable) PUMP&WEL.Ly <br /> DVA— <br /> OCT 2 B 6WIRONMENTAL HEALTH PERMIT `/ <br /> (COMPLETE IN TRIPLICATE) NN 11�(-�Uj�� � {����� <br /> WATER QUALITY <br /> Application isherebymadetothe 'tJn/�q ,L`o (Heap .L54strlctforapermittoconstructand/orinstalIthework herei n described.Th is appli cation is <br /> made in compliance with San Joa ri' Enf C r�dinanc e11o. 1862 and the rules and regulations of the San Paquin Local Health District. <br /> Exact Site Address a/S'G �l ,1 City/Town <br /> Owner's Name Phone _/ <br /> Address _,,2_y 1-4- S' 4 Q City <br /> Contractor's Name D License#1{r.�-3 2-1 Business Phone <br /> Contractor's Address oEmergency Phone �� --FC 2- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Swrface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �Cc�ysc <br /> T�ype�f Pump er H.P. -- <br /> PUMP REPLACEMENT: E; State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <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. 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 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." <br /> I will I for �Groutlnsyfttlon prior to g uting and a final insp ' n. f y <br /> Signed XItle: Date: f J .=J ) <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY f <br /> PHASE I rG GL_ ! <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase I Grout Inspectione III Final Inspection bn <br /> t hSA0214.9 <br /> Inspection By N Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> FEE S tL 00 <br /> LESS 11 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Iss ance Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />