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r Applica i� VlbW.P'ra#Aii�Wiie�1 S ited Properly Completed. Be Sure To Sign TheApplication. u n <br /> FOR OFFICE USE: <br /> ( PLICATION est, �� �1T' f <br /> �} R 1�fai�n-Transtera6le, Revocable,5uspendable) <br /> � � PUMP&WELL <br /> r I ENVII�Q ENTAL HEALTH PERMIT <br /> iSAN JOA'Qjtjjq I- WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) �� �}STR;C <br /> Application is hereby made to the San ocaRieafth District for a permit to construct <br /> and/or install the work herein described.This application is <br /> made in compliance with San J�o^aq iirl County Ordinance No. 1662 and the rules and r gulations of the San JoaqW Local Health District. <br /> Exact Site Address. C� - -� �p City/Townur ,a�. <br /> Owner's Name Phone <br /> Address �r d City <br /> Contractor's Name Purviance D_n ers ril ing C01i License Business Phone <br /> Contractor's Address 19, G S Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes J/ No <br /> 16 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ---� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © " PUMP INSTALLATION ® PUMP REPAIR❑ <br /> REPLACEMENT❑ f <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 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN '_ -Gauge of Casing <br /> B-IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> irs <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER �' Other Information <br /> ❑ GEOPHYSICALSurface Seal Installed By: <br /> PUMP INSTALLATION: r/ Contractor Pu ianee Dri <br /> i Type of Pump.= <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 13State Work.Done <br /> i 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 /> Home owner or licensed agent's signature certifies the fallowing:"I certify that in the performance of the work for which this per <br /> is issued, I shall not employ any person in such. manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature_certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of Californsa." <br /> I will call for a o Ins p ction prior to grouting and a final inspection <br /> R <br /> Signed X Title: y _n , <br /> Date: ' /O_ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> � �rt- <br /> PHASE I k `` Date <br /> Application Accepted By <br /> Additional Comments: rt <br /> Phase It Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date inspection•By� <br /> ac,� Date <br /> Fee IS Due: 13 ANNUALLY ❑ PER'UNIT'- - 1❑ PER SITE-`- ❑ EACH ❑ January 1 &-Received"By January-31 ❑ July 1 d Received By July 31 <br /> ____F_ -1: -- REMIT <br /> BASE" EXPLANATION BILLING "REM477ANCE' - AMOUNT DUE CHECKED <br /> I DATE DATE RE ED AMOUNT <br /> — <br /> (2o [ <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> o- <br /> OTHER <br /> OTHER > <br /> lssu$ cea Mailed <br /> Received by � Date ?:' Receipt No. Permit No. Delivered <br /> i 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON, A <br />