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Applications Will Be Processed When SubmittedProperly Completed. � �t r�lg app+icanon. �J <br /> A �'?FFICE USE: <br /> (For Non-Transferable, Re le e b e) <br /> PUMP&WELL <br /> ENVIRONMENTAL H TH NPEEF�n1�4T 1979 � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 11JJ ��77 <br /> Application is hereby madetotheSan Joaquin Local Health Districtforapermittoconstructa dlRrgs�#�th� ereindescribed.Thisapplication+s <br /> made in compliance with San Joa uin CountVOrdinance No. 1862 and the rules aam tti�n­ <br /> o quin cal Health District.Exact Site Address G l_11,�t�.�a �"� tty/Town <br /> Owner's Name Phone 27 r Z� <br /> Address O City <br /> Contractor's Name License#&3-3 73 Business Phone 4 <br /> Contractor's Address Emergency Phone G"�7:C. r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No OOP <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ R <br /> WELL CHLORINATION ❑ WELL ABANDONMENT go' 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 <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 7 <br /> ❑ GEOPHYSICAL Su face Seal Installe By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / •c-'-^��'�`�i.-J? H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0 State Work Done p-1-r� P <br /> DESTRUCTION OF WELL: Well Diameter 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wit II for a Grout In ectton prior to outing and a final inspection. <br /> Signed X Title: Date: ! / <br /> (Draw lot Ian on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE t / <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Spec on Phase III Final Inspect on <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE w <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY �7 <br /> OTHER —n FA <br /> OTHER <br /> 1-1 sl -71 <br /> Received by Date Receipt No. Permit No. Issuance Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />