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Applications Will Be Processed When Submitted Properly Completea. <sa e I ' r ^rr• <br /> FOR OFFICE USE: APPLIC'ATIO <br /> a <br /> (For Non-Transferable, Re 1� � ) PUMP&WELL <br /> ENVIRONMENTAL H� TH PERM T4 19$o <br /> WATER QU Y �A� <br /> (COMPLETE 1N TRIPLICATE) rein described.This application is �� <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermittoconstruct and! r 04th r <br /> �,.p,,�� `�^' { "401 qui Local Health District. <br /> made in compliance with San Joa uin County rdina ce No. 1862 and he rules ar1Q4y► "lid `O �� 21 <br /> ►-Ci / <br /> Exact Site Address awn <br /> TPhone ! 3 l" <br /> Owner's Name �`. <br /> City ,r <br /> Address License#/G),3 73 Business Phone 546(1 <br /> Contractor's Name �cr� <br /> Contractor's Address Emergency Phone <br /> 1s Certificate of Workman's Compensation I surance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C3 DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER 11 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 <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: <br /> PUMP INSTALLATION: Contractor / <br /> 00 <br /> Type of Pump H P' <br /> i <br /> PUMP REPLACEMENT: Sate Work Done 'J <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 !a <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 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 /> 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 California." <br /> I w' tail for a Grou spectian prior 6grouting and a final inspection. <br /> Signed X <br /> Title: Date: --)-3 46 <br /> Plot Plan on Rever Side) , <br /> OR EPARTM T USE ONLY �a <br /> FApplication <br /> ASE I Date0 <br /> o U <br /> Accepted By <br /> ditional Comments: <br /> Phase 11 Grout Inspection Ph Final pection �y. elo <br /> Date �� Inspection By Date <br /> Inspection By a <br /> Fee 1s Due: ❑ ANNUALLY PER UNIT PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date Receipt No. Permit No, Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />