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Applications Will Be Processed When Su ml a <br /> - - � APPLICATION \ , <br /> FOR OFFICE USE: (For Non-Transferable,Revocab sll PUMP&WEL�- <br /> ffMIT <br /> ENVIRONMENTAL HEI ' 19a1 j — <br /> N-- - -'~ WAVER QUALIT ��B application is <br /> (COMPLETE IN TRIPLICATE) D a N LTf'�' �� <br /> ipt'Local Health District. <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto consdtr ectU adoo s oftt g iNnork her In described.This <br /> �, iw� <br /> made in compliance with J aquin ounty Ord' ace No. T2 an the r) 9 r{4t�j'; .i~.- o <br /> Exact Site Address Phone � 10- <br /> Owner's Name ',1� � X�7�773� <br /> Address 4 3 License#��= Business Phone <br /> Contractor's ame Emergency Phone <br /> Contractor's Address NO <br /> Is Certificate of Workman's Compensation In ranDEEPEN D With SRECONDITION❑ DESTRUCTION❑ r. <br /> NEW WELL I� PUMP REPAIR❑ <br /> { TYPE OF WORK (CHECK): -` <br /> G WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION y <br /> E REPLACEMENT❑ Sewer Lines <br /> Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspocl/seepage Pit Other <br /> t Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well _ <br /> TYPE OF WELL � �Y <br /> INTENDED USE } CABLE TOOL Dia. of Well Excavation e" <br /> I ❑ INDUSTRIAL ❑ LLED Dia. of Well Casing <br /> [3pRI <br /> DOMESTIC/PRIVATE ❑ pRILLE Gauge of Casing <br /> tt VOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> IRRIGATION ROTARY Type of Grout <br /> 1: <br /> 13 CATHODIC PROTECTION ❑ OTHER Other information <br /> ❑ DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor H,P. Q <br /> pUMP INSTALLATION: Type of Pump <br /> ❑ State Work Done t <br /> PUMP REPLACEMENT: �-( <br /> PUMP REPAIR: ❑ State Work Done Appro)tirnate Depth t <br /> Well Diameter i <br /> DESTRUCTION OF WELL: Wef <br /> Describe Material and Procedure i <br /> i I hereby certify that 1 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 Loca! Health District- <br /> Home owner or licensed agent's signature certifies the following:1 certify that in the performance of theworkfar s which allspermit <br /> kman's compensation <br /> is issued, I shall not employ any person in such manner as to become g. 1 certify thsubject toat intheperformance of theworkforwniioch this <br /> Contractor's hiring or sub-contracting g attire tortworkman'sifies the 1 compensation laws of California." <br /> permit is issued, I shall employ persons► <br /> I will call for a.Grout Insplction prior to grouting and a final inspection. pate:,- . <br /> Signed X (praw Plot Plan on Reverse Side) <br /> f FOR DEPARTMENT USE ONLY <br /> kb <br /> PHASE l � Date `— <br /> f Application Accepted By <br /> Additional Comments: s III l Inspection 11 <br /> Phase Il Grout inspection Date <br /> Inspection By <br /> 'Date _ inspection y <br /> 31 <br /> REMIT <br /> Fee IS Due'. ❑ ANNUALLY <br /> CJ UNIT ❑ PER SITE ❑ EACH ❑ January 1 eceivr$By January 31A ❑TJpUE S ReCeICH CKEDved By y ' <br /> _ - REMITTANCE REMITTED <br /> BILLING AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE �^ , <br /> LESS <br /> f PRORATION <br /> PLUS C 4�h tom+ <br /> PENALTY ' <br /> i <br /> k OTHER r . <br /> l OTHER <br /> 4 Is uanc Date Mailed Delivered. <br /> ipt No. Permit No. CA 95201 <br /> Received by <br /> • Date Rece1601 E.HAZELTON AVE„ Dox vx 2009 STOGKTON, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH VERMITlSERYICES - _ - <br />