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A ti S II o s W ubmlttea Pro en t:ompleteu. ceoura ,w—v- •.�^rr••�•••-- <br /> qR aF!;icE USE: t APPLICATION <br /> (For N ansferable, Revocable, Suspendable) <br /> MAY 12 191 PUMP&WELL <br /> HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE�nn WATER QUALITY <br /> Application is hereby mad <br /> a 6istrict for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San At �dYlU No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 4 City/Town <br /> Owner's Name & ®^ ""� Phone <br /> & rl � 7 }y <br /> Address City _ oC]— <br /> Contractor's Name License 4&2-?7,3- Business Phone— " 7 <br /> •U r <br /> Contractor's Address /��z _ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHL.ORINA >ON ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTEI <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 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <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 /> Ty e of Pump H.P. <br /> PUMP REPLACEMENT: estate Work Done -FAK <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> C:), <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work fo"r 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 Inspection prior to grouting and a final inspection. <br /> Signed X Title: 7 a-se.� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _1 � <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P a III Fi al 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 $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED S AMOUNT <br /> FEEf ~ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu nce Dat Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />