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A tions Will Be Processed W of pubmittedProperlycomplerea- ne auras rw­w •�rtrr -- <br /> FOR OFFICE USE: NOV 3 0 APPLICATION' <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> SAN LIENV II30NMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)HEALTH d[S f Klu WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordnance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address <br /> Q v 6 I6"- ct City/Town <br /> k <br /> L / R Ix Phone <br /> Owner's Name t t d City if fi4 <br /> Address IIF <br /> Contractor's Name CIN <br /> License#_32tL_;X5j,_Business Phone <br /> Contractor's Address fC Emergency Phone 7 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WEL2 <br /> L DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR❑ <br /> REPLACEMENT❑ t I --� pit Priv <br /> DISTANCE TO NEAREST: Septic Tank, -•--^ Sewer Lines y LL <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit _. — Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation ( 4 <br /> ❑ DRILLED Dia. of Well Casing r� <br /> _CDOMESTIC/PRIVATE „ <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing <br /> ❑ IRRIGATIONRAVEL PACK Depth of Grout Seal <br /> ROTARY Type of Grout <br /> El CATHODIC PROTECTION <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> �� <br /> Surface Seal Installed By: <br /> 13 GEOPHYSICAL t <br /> PUMP INSTALLATION: r Contractor <br /> .Type of Pump H P' ob <br /> 4 10State Work Done <br /> PUMP REPLACEMENT: F. <br /> PUMP REPAIR:, '❑ A41State Work Done w <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance.viith San Joaquin County <br /> ordinances, state laws, and rues and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agents 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." <br /> I will call for a Grout In pection prior to grouting and a final inspection. 4 <br /> Title: Dale: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> F*4,r�. Application <br /> ASE f Date — �� <br /> rt Accepted B <br /> ditional Comments: <br /> Phase III Final inspection <br /> Pha I rout Inspectiaa/ Date <br /> Inspection By Date Inspection Byree Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1 &Receiv REMIT By 1 <br /> -' BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> I , <br /> t LESS x <br /> PRORATION <br /> I PLUS <br /> F PENALTY <br /> e <br /> OTHER <br /> h• — <br /> ! OTHER _ <br /> 13cl0 LL. VReceived by DateReceipt No. Permit No- Iss ante DaMailed Delivered _I <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSEAYICES �° <br />