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Applications Will Be Processed When Submitted Proper) p;1 to es@bum q� ��t tireNNN �a � <br /> ,� *R OFFICE-USI APPLI _ <br /> (For Non-Transferabl e o t le,Suspendat* PUMP&WELL <br /> ENVIRONMENTA AL1J6E%M1T 0(-,N\- <br /> WATER QUALITY y <br /> (COMPLETE W TRIPLICATE) i?PQ � �oc <br /> Application is hereby made to the San Joaquin Local Health District for a perm ittoc�r�s �rt�Itheworkhereindescribed.Thisapplicationis , <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules n� Ions of the San Joaquin Local Health District. f <br /> Exact Site Address City/Town <br /> C—� � - 1 <br /> Owner's Name Phone <br /> City <br /> Address �- <br /> Contractor's Name , License# 4 Business Phone <br /> 0 / .2 `s <br /> Contractor's Address Emergency Phone <br /> _ ���-?"'i--� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> ❑ L <br /> WELL CHLORINATI ❑ WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pik 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 ❑ INDUSTRIAL ❑ CABLE TOOL - Dia. of Well.Excavation -( <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing a] <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i <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 /> � <br /> Type' of Pump H.P. <br /> PUMP REPLACEMENT: <br /> O - <br /> State Work Done 50 lat, <br /> I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth i <br /> F Describe Material and Procedure <br /> 1 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 /> C Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 shall employ persons subject to workman's compensation laws of California." <br /> I will <br /> call for a Grout Inspection prior/to grouting and a final inspection. <br /> l� 'i .a.„r L �,Rddsu_ Title: Dater <br /> t Signed X _+ —��'� <br /> E (Draw Plot Pan on Reverse Side) _ <br /> ry�FOR DEPARTMENT USE ONLY <br /> PHASE I \}t1__ �/�., Q� y <br /> Application Accepted By +++ Date " <br /> r Additional Comments: A� <br /> „ - <br /> f <br /> Phase 111 Final Inspection <br /> Phase II Grout Inspection' <br /> Inspection By <br /> Date Inspection By~✓1't� Date 2'7'�Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE Cl EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> # BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> A L4 OD <br /> ` FEE - 4S <br /> y LESS <br /> 1 <br /> PRORATION <br /> PLUS <br /> is PENALTY - <br /> OTHER <br /> OTHER <br /> 7/) <br /> Received by Date Receipt No Permit No. - Iss ance ate = -'Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20D9 STOCKTON,CA 95201 <br />