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Applications Will Be Processed When Submitted Properly Completed.Jt#��u��' a1upT lication. I <br /> FOR ICE US APPLICATION e\n.� (��q� �} <br /> (For Non-Transferable, Revoc +Aable) �9�1 PUMP&WELL <br /> ENVIRONMENTAL HEA 2LL���ERr'r �'� 00 fit, <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY _���\\`1 �''R �C <br /> Application is hereby madetotheSan Joaquin Local Health District forapermittoconstruct and/orir> � eDp& herein described.Thi <br /> sapplicationis <br /> made in compliance with( n Joaquin County Ordinance No. 1862 and the rules and regurof I =an Joaquin Local Health District. <br /> Exact Site Address, o � ^L Ii y/Town <br /> Owner's Name 144 ACd_9­%Az Phone <br /> Address City <br /> I r, 17 - <br /> Contractor's Name License# ��7-( Business Phone <br /> Contractor's Address 'I r`w� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION Q I <br /> WELL CHLORINATION 13 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION A PUMP REPAIR❑ <br /> REPLACEMENT 11 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy a <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> �DUSTRIAL 11 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done Pau/ 2 R <br /> PUMP REPAIR: ❑ State Work Done y" <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth C� <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 for which this <br /> permit is issued, 1 shall employ persons subject to workman's cc mpens tion lawfs of aljfornia. ; x <br /> ��•. �ir� �14 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. it,k4 7tp <br /> Signed X / � �tTitle: I a Arc✓ Date: 951 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection se III Fi al Inspection, ,,a�$/ <br /> Inspection By_ Date Inspection By Date _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July t &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S <4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuarice D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />