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ApplfCations WIII Be Processed When Submitted Properly Complete f.i3l S�i it n11h*4p&a dr� <br /> FOR OFFICE �7 APPLICATION U <br /> (For Non-Transferable, Revocab¢ Suspa le)) J U L 1 g 1980 PUMP&WELL <br /> ENVIRONMENTAL HEAL PERMIT <br /> j,^;rtI s i N LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SP,N <br /> -y <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermit toconstruct and/or ir�#CV` �lrkWW&Tr�sTribed.Thisapplicationis <br /> made in compliance withSanJoaquin County O finance No. 1862 and the rules and regulations of the San Joaquin Loc I It District. <br /> Exact Site Address / City/Town az <br /> Owner's Name Phone <br /> Address 00, �1A City <br /> Contractor's Name 4#j& License# Business Phone ,5 ��78' r�,A <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No } <br /> TYPE OF WORK (CHECK): NEW WELL 91"DEEPEN ❑ , RECONDITION❑ -DESTRUCTION❑ <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 Field Cesspool/Seepage Pit Other <br /> Property Line_ Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ I STRIAL ❑ CABLE TOOL Dia. of Well Excavationes <br /> v <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing . <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing !ZZ&14c® <br /> J. <br /> *� <br /> ❑ IRRIGATION ,❑ G��R��AVEL PACK Depth of Grout Seal <br /> ,�,,,, V <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 _ rwt � e H.P. IVV <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 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, I shail employ persons subject to workman's compensation laws of California." <br /> I will call fora Grout 1 spection prior to grouting and a final inspection. <br /> Signed X �G�af ~ y Title: ..��.-�i��sr� .eQ� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEPARTME T USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection PI se III Final Ins ection <br /> Inspection By Date Inspection B� 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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE g <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ! -715 <br /> Received by Date Receipt No. Permit No. Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />