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+ Applications Will Be Processed When Submitted Properly Completed. Be Sure To he Application. <br /> J122AFNFICE USE-N APPLICATION <br /> (For Non-Transferable, Revocable,Sm , dkle <br /> PUMP&WELL <br /> ENVIRONMENTAL H L�a IT 0 <br /> WATER U � A 'N <br /> (COMPLETE IN TRIPLICATE) Q IT pp 2� A� � <br /> Application is hereby made toth ,Sn Jgaquin Local Health District fora permit to ruct7or install the tFein described.This application is <br /> made in compliance with San Joaquin County Order ace'No.1862 an les and regulations r f I'a in L c Health District. <br /> Exact Site Address ZIr <br /> 6+tvR,TOO\5 � -7 v%-,,Owner's Name Q r <br /> none ! Q [ 17 <br /> Address City <br /> Contractor's Name License# t L z X73 Business Phone- ,!�16 (a <br /> Contractor's Address Emergency Phone .SQ w.!-- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONy,1& DESTRUCTION❑ <br /> WELL 'CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Ik PUMP REPAIRI� w <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Fiela Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE /TYPE OF WELL <br /> El INDUSTRIAL CABLE TOOL Dia. of Well Excavation.. <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing t i <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing f <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal i <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER ther Information <br /> ❑ GEOPHYSICAL 3 urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Q �^- <br /> Tye of Pump Q Y� H.P. �3 <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 <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 issu II not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Co ractor's hiri or sub-contractin signatur ertifies the following:"I certify that in the performance of the work for which this <br /> rmit is issued, I h I emplo pers s c o workman' ensation laws of California." <br /> I will call for a Inspec on p r in final inspec' �J2,it 01✓�� <br /> Signed Title: ate: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By — Date <br /> Additional Comments: <br /> *n� -I- <br /> 5b <br /> pection Phase I Fin Inspection <br /> Inspection By Date _ Inspection By - Date �2'A� <br /> 0 <br /> Fee Is Due <br /> ❑ ANNUALLY ElPER UNIT ❑ PER SITE 11EACH ❑ 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 /> 4 U <br /> FEE v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 4 ? <br /> Received by Date Receipt No. Per No. Iss ance 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 />