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f, Applications W ill Be Processed When Submitted Properly complerea. aeau. r <br /> APPLICATION <br /> OR QF,FICE USE: <br /> For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r WATER QUALITY <br /> {COMPLETE IN TRIPLICATE) <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermitloconstructand/orinstallthework herein described.Thistrioapplication iz� <br /> made in compliance with San Joaquin Cour Ordinance No. 1862 and the rules and regulations of the San Joaquin cal Health�y District. <br /> City/TownCet/t 1 <br /> Exact Site Address <br /> Phone <br /> Owner's Name City <br /> Address <br /> Contractor's Name "�� License 4�3 JQ 9?_—Business Phone <br /> Emergency Phone <br /> Contractor's Address �® OX No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes— -- <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN 11RECONDITiON L� DESTRUCTION❑ MP REPAIR❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11P OTHER ❑ PUMP INSTALLATION U <br /> REPLACEMENT❑ ' <br /> 1; Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Pit --Other <br /> Sewage <br /> Sewage Disposall Field Cesspool/Seepage ) <br /> Property Line 14/_Private Domestic Well - Public Domestic Well j <br /> INTENDED USE TYPE OF WELL /:PIf ry gam` p A` + 9 <br /> ❑ INDUSTRIAL CABLE TOOL Dia, of Well Excavation ! 1 <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing l� <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION I <br /> 11DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor ) �'�{ � "� �� SMP Sam <br /> PUMP INSTALLATION: 1/Il �C� 1 H.P. <br /> fff Type of Pump <br /> PUMP REPLACEMENT: 13 State Work Done <br /> ❑ <br /> PUMP REPAIR: State Work Done <br /> ` <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <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 /> g.. y p i <br /> Contractor's hiring or sub-contracting signature certifies the following: 'I certify that in the performance of the work for this RYy� <br /> permit is issued, I shall employ persons subject to workman's compensation Yaws of California - <br /> I will call for a Grgut Inspection p for to grouting and a final inspection. <br /> Title: � — Date: " <br /> Signed Xi <br /> (Draw Plot Plan on Reverse Side) <br /> FOR PARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> f Additional Comments: - �111F'hal pectionPhase II Grout Inspection I /DateInspectionByyY {Date <br /> Inspection By � + <br /> Suky 1 &Received July 31,x, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 5 &Received By January 31 ❑ REMITy <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED y1J <br /> I BASE EXPLANATION DATE DATE REMITTED AM�OUNNTT - r <br /> ' FEE <br /> LESS4 <br /> + PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> P OTHER -— <br /> t 7 <br /> Date <br /> Receipt No Permit No. Issuance Date Mailed Delivered <br /> Received by1605 E.HA2ELTON AVE.,AYE.,P.O.P"O.Box 2009 STOCKTON,G <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />