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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. f <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HVAL-TH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER,QUALITYt} .111 t,el <br /> Application is hereby made to the San Joaquin Local Health District for a perm it to construct and/or instal l the work,herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San JP aquin Local Health District. <br /> Exact Site Address 4 City/Town "5C81 Ori ' <br /> Owner's"Name � �1; a Phone 838-2245 <br /> Address t, City <br /> lr'Contractor's Name a License# _76.9- 'Busin�ss Phone — 1 <br /> Contractor's Address71 n ww":l ri zS d Emergency Phone _ t' <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes_ No _ r <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ I J <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 /> ' i <br /> 11INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing <br /> ❑ DOMESTIC/PUBLIC,.,, I ❑_DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACKK F� -'—Depth of Grout Seal <br /> t y <br /> E] CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information �} <br /> ❑ GEOPHYSICAL I I Surface Seal Installed By: t!� <br /> PUMP INSTALLATION: Contractor MO rm S,Water <br /> Type of Pump /ice H.P. <br /> PUMP REPLACEMENT: i i ❑ State Work Done <br /> PUMP REPAIR- I. State Work Done l <br /> DESTRUCTIONOF WELL: Well Diameter Approximate Depth . <br /> Describe Material and Procedure I n <br /> r <br /> I hereby certify that 1 have prepared this,applicationand that the work will be done in accordance with San Joaquin County <br /> f _ ordinances, state laws,find rules and regulations of the.San Joaquin Local Health District. } g <br /> Home owner or licensed lagent'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:"l certify that in the performance of the work for which this 7 <br /> permit is issued, I shall mploy persons subject to workman's compensation laws of California." E <br /> - r. . ' y <br /> I will f r a �I *tion prior to grouting and a linal inspection. <br /> Signed X CO—Owner e Date: 12-7-82 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> // <br /> PHASE I : Vb <br /> Application Accepted By '� Date <br /> Additional Comments. ,M l <br /> Phase 11 Grout Inspection Phpa a III Final Inspection <br /> E <br /> Inspection By M G1 Date Inspection By ; Date <br /> Fee Is Dug: ❑ ANNUALLY I❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 F❑ July`4 &Received By July 31 <br /> r j ; REMITr <br /> BILLING REMITTANCE $ k AMOUNT DUE `CHEGKED <br /> BASE EXPLANATION 1- <br /> 'DATE DATE REMITTED ; tt� AMOUNT <br /> FEE <br /> LESS (. <br /> PRORATIONPLUS <br /> I 33( <br /> ' PENALTY <br /> OTHER <br /> r OTHER Illy i <br /> C v <br /> .. -{ Received by - Date.l� —Receipt No.^� •� -— Permit No.'--. _ - Issue ce D to Mailed - Delivered <br /> 'iLL� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br /> Ilii - <br />