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' - Applications Will Be Processed When Submitted Properly Comae B Le n The Application. <br /> FOR OFFICE_ME.,;,-'_ APPLICAT11 y <br /> (For Non-Transferabl vt -spendable) <br /> O <br /> i ENVIRONMENT EALT"EP R,[IAW�� PUMP&WELL <br /> C;;11 <br /> (COMPLETE IN TRIPLICATE) WATER LITO VC)cPL <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstru t.ap!9 yytu� tai hr�,�orkhereindescribed,This application is <br /> made in compliance with, a��tatu�in(tQgnty nance N . 1862 and the r�le ]re�yul 4,n % tfi Sarl.Qoaqujp Igbcal Health District. <br /> Exact Site Address��O �y .� / -�� City/Town ,/1 <br /> Owner's Name Phone O <br /> Address 2 City trK� <br /> Contractor's Name _1 ss ��1 /�.� ;. /. _ _. License#`G�3,? Business Phone <br /> Contractor's Address /3 6 � �r Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on FIB With SJLHD4 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ -, <br /> REPLACEMENT B� <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 'I TYPE OF WELL <br /> ❑ INDUSTRIAL h ❑ CABLE TOOL Dia. of Well Excavation <br /> l ©'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 'Cl GRAVEL PACK Depth of Grout Seal. <br /> l ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor . � ,41 19 <br /> t- <br /> Type of Pump H.P. n <br /> PUMP REPLACEMENT: aKstate Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> a DESTRUCTION OF WELL: Weil Diameter Approximate Depth <br /> 'Describe_Material-and <br /> ,Procedure_, <br /> 1 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 fofldwing:"I certify that in the performance of the work forwhich 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 /> r Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this -� <br /> t permit is issued, I shall employ persons subject to workman's-compensation laws of California." <br /> I wi 1 11 fo a Grout In ction prior to gr uting and a final,inspection. / Dill C <br /> Signed XT Title: GY3/ Date: f'4 <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I d-1 <br /> Application Accepted By Date 144 <br /> Additional Comments: <br /> z,-wl Phase II Grout Inspection ha III Final Inspection 1 <br /> Inspection By- Date Inspection B Dates <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January LA 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 /> T <br /> f FEE <br /> r _ <br /> LESS <br /> PRORATION <br /> PLUS <br />�. PENALTY <br /> OTHER <br /> 4 OTHER <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> "APPLICANT—RETURN ALL COPIES TO! t ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE,;P,O.Box 2009 STOCKTON,CA 95201 <br />