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Applications Will Be Processed When Submitted Properly Completed.BeSureTo SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> s (For Non-Transferable, Revocable, Suspendable) <br /> RUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> p - f <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetothe 4ho in �tri�ra mittoc ct ri s Ili ework herein described.This application is <br /> made incompliance with San Joaquin/ my Ordinance No. 1862 and n, egulations of the San Joa�yin Local Health District. <br /> Exact Site Address / G rn1A /II/a�� Mf City/To <br /> wn �+� � <br /> Owner's Name / ! l ` f/•v� r �` r Phone <br /> Address I City— <br /> :,r <br /> ity 'f <br /> Contractor's Name License# B}Asiness hone �' s^�� 5�.3 � <br /> Contractor's Address 3 �°� /�L, eOnW Emergency Phone (��4yr9r0` 4/3 e� <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 P;'-'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 I/ <br /> ❑ INDUSTRIAL ,❑, CCA LE TOOL Dia. of Well Excavation <br /> 13DOMESTIC/PRIVATE 94"GRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing A <br /> 1 ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal � /q <br /> „� ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ OTHER Other Information <br /> a, 0] DEPOSAL <br /> Zi/GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Y <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <br /> DESTRUCTION OF WELL: Well Diameter 5.! Approximate Depth <br /> 20 <br /> Describe Material and Procedure /1,47-7 <br /> G/r L C <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 rues 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 - r <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 ' ued hall employ persons subject to workman's compensation laws of California." <br /> '� wi ox out In �toouting B�ndsinalin tion.Signed Xle: ... Date: r f D <br /> 1 (Draw Plot Plan on Reverse Side) .01 <br /> FOR DEPART ENT USE ONLY <br /> E PHASE I ,� <br /> Application Accepted By �r 'rte �� Date U <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III 'n 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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNTDUE- CHECKED <br /> k DATE DATE REMITTED �f AMOUNT <br /> F FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> rn /,5 <br /> Received t)y I Date Receipt No. - Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />