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FC:. V;FFICE USE: APPLICA V fJ v <br /> Non-Transferable, RevSuspenndable) <br /> ENVIRONMENTAL HEH P RAlPUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ��pp c'\Qu1N <br /> Application is hereby made to the San Joaquin Local HealthDistrictforapermittoconstsh:NVy-�,, tiRtl���neWrtR-'�ereindescribed.This application is <br /> made in compliance with San Joaquin County Ordil ance No. 18[62 and the rules and.re4ii 6 ions of the Sa J u LL a Health District, <br /> Exact Site Address�_Q J<Irp !/, / City/Town <br /> Owner's Name Phone -V_/ L/ <br /> Address City <br /> Contractor's Name J. License#J(�,13 Z,3 Business Phone �_( ��„ � <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insuran on File With SJLHD? Yes r No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ r <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 /> INTENDED USEY <br /> T PE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation + <br /> I ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ dRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I © GEOPHYSICAL <br /> Surface Sea Installed By: <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done ter. _ pis.—yy <br /> I DESTRUCTION OF WELL: Well Diameter U Approximate Depth <br /> Describe Material and Procedure <br /> E 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:9 9 g:"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 of California." <br /> I Wil II for Grout I pe prior to grou ng and a final inspection. /�p <br /> Signed X if Title: Date: <br /> (Draw Ko Ian on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By date ��L <br /> Additional Comments: <br /> Pha a 11 Grout Inspection Phase I Final Inspection/ <br />! Inspection By Date Inspection By AeLt Date <br /> i Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Pi PER SITE ❑ EACH ❑ January 1 8,Received By January 31 ❑ July t &Received By Jury 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE .REMITTED AMOUNT <br /> FEE <br /> LESS 7 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � `a5 <br /> —t�1 ~5 7 <br /> Received by Date - Receipt No. -Permit No. -Issuance Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HATELTON AVE.,P.O.Box 2009 'STOCKTON,CA 95201 <br />