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A pltc ti s ]-1ge"rot ss0W uAPPLICATION bmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: i <br /> (For ransferable, Revocable, Suspendable) PUMP&WELL <br /> NO $ 1986VIRONMENTAL HEALTH PERMIT <br /> COMPLETE IN TRIPLICAT r., r. f S,WATER QUALITY i ., „r. �j — VWQ ^t 7 <br /> Application is hereby made tothh. SanJoa u. Lo fyJi Istricttorapermit toconstruct and/or instalIthe work,hereindescribed.Thisapplication is <br /> made in compliance with San Jo q Intdoun�y�rdlM ee NDo. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address m+�A a -;— glCity/Town t <br /> / T <br /> Owner's Name V' i Phone <br /> Address G S74 �r•. City x <br /> q � <br /> Contractor's Name !>9,/ � - License#�16_537-2 Business Phone ''�- �— / d S 1 <br /> Contrac'tor's �Address ��v Lg�Z J755.�-/- Emergency Phone ' ' �/ <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 /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIRLYJ <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal FieldCesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br />+ INTENDED USE -TYPE or-WELL t <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ,, S <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 <br /> H.P. <br /> PUMP REPLACEMENT: ❑ tate Work Done ' <br /> PUMP REPAIR: E state Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <br /> `J <br /> Describe Material and Procedure <br /> I hereby certify that'l 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'l certify that in the performance of the work for which this permit I <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 theperformance of the work forwhich this <br /> subject to workman's compensation lavas of California." <br /> permit is issued, I shall employ persons � , <br /> I will call for a Grout Inspection prior to grouting and a line] inspection. <br />• Signed X - - <br /> f' Title: Date: <br /> (Draw Plot Plan on Reverse Fde) P <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> .Phase II Grout Inspection Pha, III Fin I lU5(sectian� <br /> Inspection By Date Inspection By Date <br /> z-1:�L <br /> Fee IS Due: E3ANNUALLY ❑ PER UNIT ❑ PER SITE —1 EACH El January'1 &Received Fly January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r , <br /> FEE l7 f <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br />�. <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA45201 <br />