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Appllcatio sf1fY 1l t P c ed��W n Sub+ilitted Properly Completed. f3aSureTo51gn 1neRppticauan. <br /> .FOR-,�ICE USE: L1 ,: APPLICATION <br /> (For Non-Tranifera�le, Revocable,Suspendable) PUMP&WELL <br /> SEP 4NM ; 1 <br /> �NMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) SAN JOA r nr., WATER QUALITY <br /> Application is herebymadetotheSanJL1l I e th �is'tri ra ermit to construct and/or install the work herein described.This application is <br /> �jj Gfo p <br /> made in compliance with San Joaquin Co ty Ordina!n' T�tdL4 62 and the rules and regulations of the S J a L cal Health District. <br /> Exact Site Address 7 Q City/Town <br /> Owner's Name Phone 3 0 <br /> Address O City <br /> Contractor's Name License#/6 :� 3� Business Phone Z, <br /> Contractor's Address Emergency Phone �� r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 4' 1 No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION 1:1 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 /> NTENDED USE TYPE OF WELL <br /> I DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ D MESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ D MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> i <br /> ❑ I IGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ C THODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ ISPOSAL ❑ OTHER Other Information ' <br /> ❑ EOPHYSICAL ' Surface Seal Installed By: <br /> UMP INSTALLATION: Contractor �/'�-'P l <br /> Type of Pump W.P. �-- <br /> L _ <br /> PUMP REPLACEMENT: 13State Work Done <br /> PUMP REPAIR: B`State Work Done <br /> DESTRUCTION OF WELL: We11 biameter' T Approximate Depth <br /> r 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. l <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 <br /> I will Z I for Grout Ins ctlan prior to grouti and a final ins p tion. <br /> Signed X r e: Date: �Y / <br /> (Draw Plot Plan on Revers Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection As,e,ky� al InspectionInspection By Date Inspection Byfifes Date <br /> 11 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT © PER SITE 0 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 /> y <br /> 6' <br /> PEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER nn <br /> �t <br /> Received by Date Receipt No. Permit No. I uance Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 J <br />