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AP I io i VYjA 413141ceiseAhbmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFF.LgE USE- ftJAPPLICATION <br /> [ AR ' 1981Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE)$ALL��N����°�ORjj*.Q� UI�N"�[L'�OCcAL WATER QUALITY <br /> Application is hereby made to theW9,66TUn CocOINbalth District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordi nce No.1862 and the rules and regulations of the San Jo quip Loral Health District. <br /> Exact Site Address City/Town <br /> Owner's Name r Phone t <br /> Address - ` , ity <br /> Contractor's Name icense# siness Phone } <br /> Contractor's Address EmergencyPhone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No s <br /> TYPE OF WORK (CHECK): NEW WELL❑ _DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR Ili. <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 /> 4 <br /> INTENDED USE TYPE OF WELL <br /> ZDUSTRIAL 1:1 CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal l <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> C1 GEOPHYSICAL , <br /> PUMP INSTALLATION: _ Contractor 3 <br /> Type of Pump H.P. - <br /> PUMP REPLACEMENT: ❑ State Work Done - ~ <br /> PUMP REPAIR: tate Work Done ` " <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 /> Horne 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws f California." <br /> I will call for a Grout Inspection pin r to grouti and a final inspection. <br /> Signed X Title: te: <br /> `(Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By. f Cit .Date 2� <br />` Additional Comments: <br /> Phase I rout Inspection as I ction G <br /> Inspection By Date Inspection B Date ~p <br /> Fee Is Dile:U ANNUALLY ❑,PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> yBILLING '.REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS -- . <br /> PENALTY <br /> l OTHER <br /> OTHER <br /> R <br /> - Received by - Date Receipt No. -PermitNo. 'Issuanc43 pate Mailed Delivered <br /> 4 <br /> '� APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA9i 5201 <br />