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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -FOR OFFICE USE: ' APPLICATION <br /> �( V + I <br /> (For Non-Transferable, R� b `L.p e) <br /> PUMP&WELL <br /> ENVIRONMENTALTH PERMIT �98� <br /> (COMPLETE IN TRIPLICATE) WATER QU SEP i 1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to co tructand/orinstalllt eyyeAVerein described.This application is <br /> made in compliance with Sj;gP�CpuntY,l�rcl ri , . 1 an u�aLWDWJM��+ at+ quin Local Ith strict. <br /> Exact Site Address �jj�1 L ®� �t T Y OW f <br /> Owner's Name � / +�y ` Phone 4? v J <br /> I AddressCity <br /> Contractor's Name .� 1—j�� License# I / !Business Phone <br /> t Contractor's AddressEmergency Phone <br /> Is Certificate of Workman's Compensation Insur ce on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <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 USE TYPE OF WELL. �- �, - _ JJ - <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation < <br /> M DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> i ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout 4�l <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL _ / ace Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 /> Homeowner or licensed agent's signature certifies the following:"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 /> I Contractor's hiring o Au <br /> b-contracting signature certifies the following:"I c that in the performance of the work forwhich this <br /> permit is ' all es subject to workman's -ompen n laws of California." <br /> I will all f o t I p�ection for grouting a d a final inspect' n. <br /> Signed X Title: Date: <br /> i (Draw Plot Plan on Reverse Side) ` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE f _ <br /> Application Accepted By �^"`� `�—`""^� ` Date <br /> k <br /> Additional Comments: <br /> i <br /> K <br /> Phasgek.11 Grout Inspection 1-� Phas I 1 Final Inspection)) <br /> I Inspection By ate � -12 ' 90 Inspection By Date I0 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> I BILLING REMITTANCE $ - <br /> BASE EXPLANATION PATE PATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE g$ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> k OTHER <br /> Cd I <br /> Received by Date Receipt No. Permit No, Isisuanck Date Mailed Delivered - <br /> APPLICANT�RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 952011 _ <br />