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Applicata ' tend When Submitted Properly Completed. Be Sure T SI a Application. <br /> F,OR,OFWE USE: K ' APPLICATION " <br /> -� (For Non-Transferable, Revocablg�SGS a )�! ` <br /> l` <br /> ENVIRONMENTAL 7t�MIT q PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUA . <br /> I <br /> Application is hereby madetatheSanJoaqumLocalHealthDlstrictforapermitto �structab'd/orinstall the irvoaCc,',i�reindescribed,This applicatiorris <br /> made in compliance with San Joaqui County Ordinance No. 1862 and the rules and,regulationsndT:'the'Sa�1 (�a uin Local Health District. <br /> Exact Site Address �(� ;2V w7 N� o, A <br /> Owner's Name Phone <br /> �-tn _ a tD• may' <br /> Address P, Q• S City 1 <br /> Contractor's Name License#L 9 Business Phone <br /> Contractor's Address Emergency Phone d <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 7 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 0 DESTRUCTION❑ <br /> WELL CHLORINAN ElWELL ABANDONMENT ElOTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT <br /> EI <br /> DIS�ANCE 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 USE TYPE-OF-WELL- ®.. _..-�- - <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK - Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ; <br /> ❑ GEOPHYSICAL Surface.Seal Installed By: t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump - H.P. <br /> PUMP REPLACEMENT: State Work Donej <br /> PUMP REPAIR: ❑ State 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 fallowing:"I certify that in the performance of the work forwhich 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 /> � 4 <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 /> 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: .- �. Date: <br /> (Draw Plot Plan on Reverse Sli&) - - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By © Date -30_91 . } <br /> Additional Comments: F <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date I <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT -❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By July 31 # <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED j AMOUNT <br /> SEE S✓ LFS Q <br /> LESS. 1 <br /> PROATIONPLUS <br /> PENALTY r ! Z <br /> I 4f I Ar <br /> OTHER %1 <br /> . Ie0�6 cm, hej� S .r !a I <br /> lz1'7 � r i <br /> OTHERG.fltYe d� a ly III I�r' a-I�rr ell peep - <br /> q q 41 A i LewryA,t 4v r_ <br /> Lvik1 t+rrifI`l �{ 26�� <br /> Received by Dall <br /> rv0, ceipt%D. Permit No. . y Issuance Date Mailed Delivered p <br /> APPLICANT—RETURN ALL C TO: MENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />