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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> l `111 <br /> co PA-0p MW lir- ble) PUMP&WELL <br /> V <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUAIXTT <br /> Application is hereby made to the San Joaquin Local HoiaithDii~, fora permit tocorsstl tand/orinstalltheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 nd the rule nd gulations of the San Joaquin cal H alth District. <br /> Exact Site Address 6 City/Town _ t a <br /> r <br /> Owner's Name �! . T>1` Phone <br /> Address City <br /> Contractor's Name Lic nse#oW j2 tsusiness Phone <br /> Contractor's Address a0 Emer9ency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Wi SJLHD? Yes K No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP R€PAIRM <br /> REPLACEMENT❑ <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 /> ❑ INDUSTRIAL ❑ 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 <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thew'ork for which this permit <br /> is issued, I shall not employ any person in such manner as to become subjectto workman's compenstion 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, I shall employ persons subject,to workman's compensation laws of California." <br /> I ill call for a Grout Inspectio t y gro g and a final inspection. <br /> Signed .VC"r= -"Title: 4PO-40-`f Date: <br /> (DrawPI0 Plan on Reverse Side) <br /> FOR-OEPA MENT U E ONLY <br /> PHASE <br /> Application Accepted By ONA Date 3 d <br /> Additional Comments: <br /> Phase II Grout inspectionPhase l Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT t,a.PER SITE Q EACH ❑ January 1 8 Received By January 31 ❑.July 1&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLAN ION REMITTED DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE e14t7r L� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER .. -, <br /> I-ZT6 --3-7-T d v <br /> RZO.W byDate - Receipt No. Permit No. Issuance Date Mailed Del vefed <br /> APPUQAf—RETURN ALL COPIES TO; ENVIRQW-11ENTAL HEl1SET# - :_ ,.,160tE,HAZELTON AVE,P10.'BOx 2009 STOCKTON,CA 95201 <br />