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} aIi*AMA MeP76cetled n Submitted Properly Completed. Be Sure To Sign The Application. <br /> :. ,..caR OFFICE USE:11 APPLICATION <br /> AUG 2 2 1983(For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> onUIN IRONMENTAL HEALTH PERMIT <br /> AD�S�i RIFT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLIC + <br /> i ?t T� <br /> Application is hereby madet nJoaquinLocal Health Districtforapermit toconstruct and/or install the work herein described.This application is <br /> I made in compliance with San Joaquin County inancp-f o. 1862 and the rules and regulations of the Sa�aquin L cal Health DiArict, <br /> If <br /> Exact Site Address �S�_ City/Town ��: —, (; ¢f <br /> Owner's NamiO) Phone <br /> Address �a City t+ <br /> Contractor's NameLicense# +W Business Phone L �T <br /> 1. <br /> Contractor's AddreEmergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4�_/ No 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR l� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy (� <br /> Sewage Disposal Field Cesspool/Seepage Pit Other v ; <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 y <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing cv{ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal "V <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br />€ ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 4,urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor__" 4� <br /> k Type of Pump .h,1- H.P. <br /> k PUMP REPLACEMENT: 1❑ State Work Done <br /> PUMP REPAIR: � State Work Done pr P <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 /> Home owner 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 r. II fora rou Inspection prior to grouting and a final m J tiioon. i ` <br /> Signed X . e � .-� ,Y Title: d �� Date: <br /> �,aw Plot Plan on Reverse <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By �U`}( Date <br /> i <br /> Additional Comments: <br /> Phase II Grout Inspection PhaseI inal Inspection �L) <br /> f Inspection By Date Inspection By Date <br /> 1I 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 $BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED <br /> AMOUNT <br /> FEE A 45 <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY _ <br /> I <br /> OTHER 1 <br /> OTHER <br /># Receive by Date Receipt No. Permit No. Iss ance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />