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Applications Will Be Processed When Submitted Properly Completed. B"66 To;S.' 7eI 'on. <br /> FOR OFFICE USE: APPLICATION E� <br /> (For Nan-Transferable, Revocable,S s dable) PUMP ELL ll <br /> ENVIRONMEN"I- 4' ALTH PERMII�� } � 81 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> r <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct anSAMst,0llt�""Ih C&kcribed.Thisapplicationis <br /> made in compliance with San.Joa uin County Ordi a e NP. 1862 and th rules and r Iatie 4sFdTA1TEa i 4RAVLP I ealth.District.. <br /> Exact Site Address G4' City/Town <br /> Owner's Name 10 . <br /> r ' Phone "` <br /> 077 <br /> Address <br /> . ; city- , <br /> Contractor's Name 1' [ ' License it 16217.3 Business Phone lnr(967, <br /> Contractor's Address _�t3 Age X Q z:-7Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ­ <br /> X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN❑ RECONDITION❑ DESTRUCTION❑ � <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ _w _ �:W— — 1 <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank . V`_Sewer,Lines a �F ;Pit Privy <br /> Sewage C7isposal Field. 's. _ '_�6'� Cesspool/Seepage'pit Other. - --� <br /> { Property Line R�. Private Dmoestic Weil Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> D INDUSTRIAL O.CABLE TOOL -, Dia. of Well,Excavation f <br /> IS DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well'Casing f <br /> 13DOMESTIC/PUBLIC C3 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of,GlI <br /> ❑ DISPOSAL ❑ OTHER Other Irfforrnation a <br /> ❑ GEOPHYSICAL f� Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ! [ [ # <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ?r1 <br /> PUMP REPAIR: ElState Work bone F N <br /> 4 - <br /> DESTRUCTION OF WELL: Well Diameter _"=A pProximate Depth <br /> # .^.,a `..,. +A <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 LoclRl-eaith District- <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in;the performande of 4he,work for which this permit <br /> is issue II not employ any person in such manner as to become sub ct to workman's compensatiomlaws of California." <br /> C rector's hiri orsub-contracting signal <br /> ifies the following:"I certify that in tl a_performance of the work for which this <br /> ermit is ' sued, I shall em loy per LI ct t workman's compensation laws of California:'' <br /> will call or A Ins ction r ng an final inspection. <br /> Signed Title: Date: r+ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE NLY <br /> PHASE I ; ]� p_L` '� <br /> Application Accepted By ice, ' � � ►''�-�—r Date <br /> Additional Comments: " <br /> Phase 11 Grout Inspection tease III Final Inspection <br /> VInspection By Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 0 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 AMOUNT <br /> i � y <br /> FEE / <br /> LESS 1Aj `02( <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER tc <br /> OTHER i <br /> f _ <br /> Received by Date Receipt No. Permit'No. Issuancd Date " Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2009 STOCKTON,CA 95201 <br />