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fr ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) y <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made totheSa .J aq InLocaIHealth District fora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San JoaqOrdinance No. 1862 and the rules and regulations of the San Joaquin cal Health District. <br /> ` ,� <br /> Exact Site Address City/Town _51e PC, � <br /> Owner's Name /Ci -S tl Phone 2 2-9/ <br /> Address / o B h City d ev4 <br /> Contractor's Name e License Business Phone�9/6/_ 371 <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 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation G <br /> ❑ DOMESTIC/PRIVATE ❑ DRiLLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal C <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 Gni <br /> 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 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 /> per it is issued, I shall employ persons subject to workman's compensation laws of California," <br /> Will II for a Gui Inspection for to grouting and a final inspection.f <br /> Signed X f /�,/j Title:& -STr eC 1U,-c Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO�R7 <br /> PARTMUSE ONLYPHASE ! <br /> Application Accepted By Date 11 aq 7F <br /> Additional Comments: <br /> Phase 11 Grout Inspection P 1 al Inspection l� �Z <br /> i <br /> Inspection By Date Inspection B Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & wed By January 31 ❑ July 1 &Rec d By July 31 <br /> BREMITTAN RE <br /> BILLING BASE EXPLANATION $ AM NTCHECKED <br /> DATE DAT REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY C <br /> OTHER <br /> OTHER <br /> 779 -1; <br /> 3� 1� 9.1?y <br /> ,AReceived by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> 1r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />