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pplications Will Be Processed When SubmittedProperty <br /> �1 <br /> APPLICA O <br /> FOR OFF410E USE: (For Non-Transferable,Be a U PUMP&WELL <br /> ENVIRONMENTAL TH PER IT <br /> WATER QUALITY JAN <br /> (COMPLETE IN TRIPLICATE) uin Local Health District. <br /> hereby madetotheSanJoaquinLocalHealthD'istrictforapermrulesl�gu�'ralTSlsbft'Sf1e or herein described.This application is K <br /> Application Is Y T �ailt � <br /> made In compliance with San Joaq in C un <br /> ty Ordinance No, 1862 and the <br /> Exact Site Address Phone ` <br /> Owner's Name City S <br /> Address Business Phone <br /> License#�-- <br /> Contractor's Name Emergency Phone 1 <br /> Contractor's Address No <br /> Is Certificate of Workrens n's,Compensation insurance on File With SJLHD? Yes STRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WE LL❑ DEEPEN ❑ RECONDITION t� <br /> L CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONl� PUMP REPAIR C3 <br /> WELL , <br /> f REPLACEMENT Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank e Pit Other <br /> CesspocllSeepag <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well 4 _ <br /> TYPE OF WELL ' ' <br /> INTENDED USE Dia. of Well Excavation <br /> ❑,NGDUSTRIAL C3 CABLE TOOL <br /> ❑ DRILLED Dia. of Well Casing <br /> Lb DOMESTIC/PRIVATE ❑ DRIVEN _„ n _ Gauge of Casing <br /> I ❑ pOMESTIC/PUBLIC " 13 GRAVEL PACK Depth of Grout Seal <br /> i ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ClCATHODIC=PROTECTION C3 OTHER Other Information <br /> 13 DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor H P. <br /> PUMP INSTALLATION: Type of Pump <br /> 11 State Work Done "w <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: 'Approximate Depth <br /> DESTRUCTION OF WELL: <br /> 4 Well Diameter <br /> Describe Material and Procedure <br /> r <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 /> I Home owner or licensed agent's signature certifies the following:"I certify that in the performance m 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 for which this <br /> f bject to workman's compensation laws of California." <br /> permit is issued, I shall employ persons su <br /> I will call for a Grout Inspection prior to grouutting and a final inspection. Date: f J <br /> i. _111 (�/LP,�- . !�" 1 Title: _ <br /> Signed X �..,. r.. ~ (praw Plot Plan-on Reverse-Side) <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE l Date a-3 <br /> Application Accepted By <br /> Additional Comments: IP ase III final inspection l <br /> I Phase 11 Grout inspection inspection By Date <br /> Inspection By <br /> Date <br /> ❑ January 1 &.Received.By January 31 El July 1 &Received By July 31 <br /> PER SITE ❑ EACH <br /> REMIT <br /> Fee IS Due: C1 ANNUALLY <br /> PER UNIT ❑ REMITTANCE AMOUNT t?VE CHECKED <br /> BILLING REMk$ AMOUNT <br /> BASE EXPLANAT40N DATE DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Mailed Delivered <br /> Date Receipt No. <br /> Permit No. Issuance ate . <br /> i Received by 1601 E.HAZELTON AVE.,P.D:Bax 2.009 STOCKTON,CA 9529 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />