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AA2 <br /> ic10tff B�leld Submitted Properly Completed. Be Sure To Sign The Application.` <br /> FOR OFFICE USE. t�i }� UU APPLICATION <br /> (Fo N -Transferable, Revocable, Suspendable) PUMP gr WELL <br /> AU G 2 7 1981 ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICA-�TTTI: n WATER QUALITYstrictf <br /> Application is herebymad�'t 1 j' 1j 'Ah Diorapermit toconstruct and/or i stall the work herein described.This application is <br /> made in compliance with Sa1Jdaqu� r t i ce No. 1862 and he rules a <br /> regulations of the Sa �oaq 'n Local Health District. <br /> F Exact Site Address f�tiIrL City/Towne <br /> Owner's Name t Phone <br /> AddressCity r r <br /> Contractor's Name License#f Business Phone <br /> Contractor's Address r r <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ``r No h <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIO,N❑ pESTRUCTIDN❑ - —� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ ' 'OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR G7�' '.J' <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines '~' Pit Privy <br /> Sewage Disposal Field Cesspooi/Seepage Pit Other <br /> Property Line Private Domestic Well rPublic Domestic Well <br /> TENDED U07 <br /> SE TYPE OF WELL <br /> INDUSTRIAL 11CABLE TOOL t _ w Dia. of Well Excavation <br /> DC�ESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ❑,DISPOSAL ❑ OTHER Other Information f <br /> ❑`GEOPHYSICALSurface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' <br /> Type of Pump <br /> _ 4 " c:_��� �' H.P. " I -- <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: tate Work Done y f A <br /> �. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth W <br /> Describe Material and Procedure j <br /> I heresy certify fhb 1'hV `prepar tl'th7splication-and-that-the-work-will-be dorie-inaccordance wi#h-San JoaquitrGounty_, <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 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 shall employ persons subject to workman's compensation laws of California." s <br /> I wcalif r a Grout I tion prior to grout' g and a final inspection. I ) <br /> ( l 7 <br /> Signed X Title: <br /> (Draw Plot an on Reverse ide) ; <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Acceptetil <br /> Date- ' <br /> Additional Comment <br /> Grout Inspection h Ill Final`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 t , AMOUNT <br /> FEE QL`'(' <br /> LESS �� <br /> PRORATION <br /> PLUS <br /> PENALTY - - - - - <br /> OTHER <br /> �Y <br /> OTHER <br /> Received by Date Receipt No. - - Permit No.-+t __ I uance Date MailedDelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />