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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION) I D(For Non-Transferable,RevocaylF�L�j st L4 PUMP&WELL <br /> ENVIRONMENTAL MEA p11L PlthAMMMIcTu <br /> I.i i <br /> WATER QUALIT 2 B 1981 <br /> (COMPLETE IN TRIPLICATE) JUL <br /> APPllcatlon Is hereby made to the San Joaquin Local Health District for a permit to construct an /or Install the work herein described.This application is <br /> ( made in compliance with San Joaquin County Ordinance No. 1862 and the missend re UICIO s (�Mpjp` tical Health District. I <br /> Exact Site Address <br /> ``"DI <br /> Owners NameS Phone— L <br /> 1 Atldress�� S.Ld _ '�oo City_ ���nnl—. �--_ <br /> Contractor's Name /,-1 IT-� _ --License a�-Fi.�3Jv Business Rhone_ 5> C4 <br /> t4 <br /> Contractors Address _ Emergency Phone _ —t <br /> F Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes------- No <br /> TYPE OF WORK(CHECK): NEW WELL 13 DEEPEN O RECONDITIONO DESTRUCTION11- <br /> WELL CHLORINATION O WELL ABANDONMENT O OTHER O PUMP INSTALLATION L-L-3 PUMP REPAIR O <br /> REPLACEMENTO I` <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines__—_ Pit Privy <br /> i Sewage Disposal Field _ Cesspool/Seepage Pit_ _ Other <br /> Property Line_Private Domestic Well_— Public Domestic Well <br /> i <br /> INTENDED USE TYPE OF WELL <br /> I O INDUSTRIAL O CABLE TOOL Dia.M Well EA,avation -- <br /> O DOMESTIC/PRIVATE O DRILLED Dia.of Well Casing <br /> O DOMESTIC/PUBLIC O DRIVEN Gauge of Casing <br /> t O IRRIGATION O GRAVEL PACK Depth of Grout Seal -- <br /> T O CATHODIC PROTECTION O ROTARY Type of Grout ------ <br /> 11 DISPOSAL 13 OTHER <br /> Other Information <br /> O GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump---- H.P. <br /> PUMP REPLACEMENT: 2rstate Work Done_J__.ui _c32_' :�-Qom- �-V- � �--L✓�--h <br /> I PUMP WEPAM: O State Work Done . -- -- <br /> DESTRUCTION OF WELL: Well DiameterApproximate Depth. — <br /> j Describe MPta,iai a,.,. , ,cc^nure S <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,ar,d rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certllles the following:")certify that in the performance of the work for which this permit <br /> is issued. I shall nut employ any person in such manner as l0 beccme subject to Workman's compensation laws of California." <br /> Contractors hiring or sub-contracting signature certifies the following:'I certify that in the performance of the work t,,r.viticlithis <br /> permit,c 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 __/�4- id�rL__�.JLo.n�=_.__—C �__ <br /> Title: <br /> _1!�_Qg2C✓Aay�— --__—._. Date: <br /> (Draw Plot Plan or RRecae Aide)) <br /> f/lFFOR DEPARTMENT USE ONLY - <br /> ASEI <br /> PHmate <br /> I .}L+'• �t <br /> Application Accepted BY ��" �— ---`^"'�-`-� ----------"- <br /> Additional Comments'. __— <br /> Phase 11 Grout Inspection a[it Final Inspection <br /> Inspection By—� -- Date__.._____._ __--__ Inspection ��if--- - Date <br /> `Q�-__ <br /> Fee Is Due:O ANNUALLY ❑ PER UNIT O PER SITE ❑EACH O January 1 a xmvea By January 31 O JVIV 1 A Ileo-.es By July 31 <br /> .- -__ _. - - REMIT <br /> E' . <br /> l BILLING 1 REMITTANCE 5 AMOUNT DUE :.NECKED <br /> RASE EVPLANATIDN DATE DATE REMITTED AMOUNT <br /> -- <br /> / -- <br /> FEE <br /> LESS <br /> PLUS <br /> PElIAUv — - <br /> OTHER —_-- <br /> OTHER -.. r11 <br /> nerapl No �P HV (a. dj/ M..I<0 Deb.lVd <br /> RlCPvea nY Cn,< <br /> APPLICANT-NETURN ALL COPIES TO. ENVIROMMEHTAL WEALTH PERMITraEROCE8 INI E.HAZELTON AVE.PC-ace mol STOCKTON•CA 1520, <br />