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F ..� <br /> hen Submitted Properly CompleteBe Sure a Sign <br /> Applications Will Be Processed W <br /> FOR OFFICE USE: APPLICATION <br /> •y .r_ (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTALHEALTHPERMIT <br /> WATER QUALITY <br /> istrictf <br /> (COMPLETE IN TRIPLICATE) ► <br /> Application is herebymadetthe San Joaquin Local HealthDorapermittoconstructand/or installtheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinanc No. 186 and the rules and regulations of the San agtsin Loc H alth District. r <br /> Exact Site Address S-5-412 City/Town <br /> Owner's Name Yom© Phone <br /> Address �7- <br /> City <br /> Contractor's Name / icense Business <br /> l�nee� <br /> Contractor's Address Emergency Phone ,P a T <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No rr� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> ❑ vu <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ 0 <br /> REPLACEMENT a ' <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank 4 <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE J TYPE OF WELL _ ? <br /> 11 INDUSTRIAL ti ❑ CABLE TOOL Dia. of Well Excavation <br /> ` Dia, of Well Casing . ` <br /> CKDOMEST II.0/PRIVATE ❑DRILLED �' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATI6N __,, ❑ GRAVEL PACK Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ? Type of Grout i <br /> Other Information. <br /> ❑ DISPOSAL ` ❑ OTHER-^� -^+, t F t <br /> r <br /> 11 GEOPHYSICAL <br /> IL* g Surface Seal Installed <br /> N <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done y _ <br /> PUMP REPAIR: 11 State Work Done, <br /> -.i <br /> DESTRUCTION OF WELL: Well Diamete <br /> Approximate Depth <br /> G Des'eribe Material and Procedure <br /> Pl �+ <br /> t I hereby certify that I hav` a prepared t ion and that the-work will be-done in accordance with San Joaquin County <br /> r ordinances, state laws, and rules and regulation�sIof�the"San Joaquin Local Health Distric't�.--,_ <br /> Homeowner orl censed agent's signature certifies the following:"I certify that in the performanceof theworkfor which this permit <br /> is issued, l,stiall not employ any personrin such manner as to become subject to workman's compensation laws of California." s <br /> 111 Cvntracl1.111Fo 's hiring orsub-c�niractil g signature certifies the following:"I certify that in the performance of the work forwhich this <br /> i permitis issued, I shall e , o t ersons subject to workman's com ensation laws of California." <br /> I i1 I r a G Lit cis,' prior to grousing and a final ins on. <br /> Signed X <br /> f <br /> Title.: <br /> Date: P <br /> (Draw Plot Plan on erse Side <br /> I + FOR DEPARTMENT USE ONLY <br /> FApplication <br /> ASE I Q�, � l <br /> Date <br /> Accepted Byditional Comments: <br /> Phase II Grout inspection '_, , Phase III Final Inspection <br /> f, ?. . "i K ;� Date <br /> Inspection By Date•" A �I Inspection By <br /> 11 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT f ❑ PER SITE ❑ EACH (� January 1 &Received By January 31 ❑ July 1.8&.Received By July 31 ., <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEELESS <br /> S. C90 <br /> PRORATION • <br /> PLUS <br /> PENALTY L <br /> OTHER <br /> OTHER <br /> + pate Receipt No. ermit No sue —Date Mailed' Delivered - <br /> Received'by <br /> AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL.HEALTH PERMIT/SERVICES 1501 E.HAZELTON <br />