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Applications Will Be Processed When Submitted Properly Completed. Be Surae+To 5 nJheApol�a "� <br /> FOR OFFICE LSE: APPLICATION ILi <br /> (For Non-Transferable, Revocable,Suspe ddr�le�' <br /> �''` PUMP&WELL <br /> I; I'r 1981 <br /> //���� /�/ ENVIRONMENTAL HEALTH PE11� lo�, .al�, <br /> (COMPLETE IN TRIPLICATE) 171 35 C�� WATER QUALITY <br /> Application is hereby made to the San Joaquin LocaHealthDistrict for apermit toconstruct and/or ig�4f(th�eworkherein 0ewribe'd.Thisap licationis <br /> made in compliance w' m Cou rdi an No. 1 62 d the rules and regulations of a il�'Lcc 1' D'stri-t. <br /> J, j 'L <br /> Exact Site Address �� ' � , g City/Town <br /> Owner's Name - _ Phone 5i = <br /> Address �`�,� _ __ ity - <br /> Contractor's Name ense# '.f l E} 'sin s Phone ` <br /> Contractor's Address - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes L - No _ <br /> TYPE OF WORK (CHECK): NEW WELL w DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION. PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy -� <br /> Sewage Disposal Feld Cesspool/Seepage Pit Other <br /> Property Line,/O t Private Domestic Well Public Domestic Well. <br /> INTENDED USE TYPE OF WELL <br /> q❑�INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> JE DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 2 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ITROTARY Type of Grout A'� t- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ,� / rface Seal Installed By:�, <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - � H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 F� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. W I <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 sha mploy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor' ring or sub-cdntracti g signature certifies the following:"I cer y that in the performance of the work for which this <br /> p a-rrrrf7is ed, I all employ per ns subject to workman's compensa "laws of California." <br /> lwil al t ti p r� ' nd a final inspectlo[tk' <br /> /.�i�'��i�- � <br /> Signed Title: �� Date <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I nnp y.(_ <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout InspectionP e II Fina Inspection <br /> Inspection By _ Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �'` AMOUNT _ <br /> FEE 4 G 0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> b 3�� <br /> Received by Date Receipt No. Permit No. IssGancepDate I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />