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Applications Will Be Processed When Submitted Properly Comer ova e U �m rj�l7rr <br /> FOR OFFICE USE: <br /> APPLICA0 �� �] <br /> �r <br /> (For Non-Transferable, Revspendable) PUMP&WELL <br /> ENVIRONMENTAL HE Pgl 1 1g$� <br /> / WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) O i by rein described.This application is <br /> Application is hereby made to the S Joaquin Local Health Distract ora permltto const QZfgi pP <br /> bi aaquln Local Health District. <br /> made in compliance wi a aquin County O inance 1862 and the rules and rei City/Town <br /> Exact Site Address r ' <br /> a Phone <br /> Owner's Nam City d 1 <br /> Address e <br /> License#.�0 �3/ Business Phone- , <br /> Contractor's Name / <br /> Contractor's Address .! Emergency Phon 6. <br /> Is Certificate of Workman's Comperisation Ins rance on File With SJLHD? Yes, No 1 <br /> TYPE OF WORK (CHECK): WELL ABANDONMENT ❑DEEPEN ❑ RECONDITION OTHER 0 ❑ <br /> DESTRUCTIONO <br /> WELL CHLORINATION P INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Y <br /> Sewage Disposal Field Cesspool/Seepage Pit Other F <br /> Property Line Private Domestic Well Public Domestic Well f <br /> INTENDED USE TYPE OF WELL <br /> 13 INDUSTRIAL 1. 11 CABLE TOOL m Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing R 1 <br /> 11 DOMESTIC/PUBLIC <br /> DRIVEN Gauge of-Casirig - <br /> ❑-GRAVEL PACK - - Depth=of Grout Seal v <br /> ❑ IRRIGATION ,._,-..- _ - _»..ww.- <br /> 11 CATHODIC PROTECTION e❑ ROTARY Typeof Grout <br /> i <br /> i <br /> 11 DISPOSAL C1 OTHER Other Information , <br /> ❑ GEOPHYSICAL r " - 770- <br /> i rface Se I Installed By:. - <br /> PUMP,INSTALLATION: Contractor <br /> liH.P. <br /> Type of Pump <br /> PUMP•REPLACEMENT: ' . ❑ State Work Done <br /> PUMP REPAIR: " " ❑ Stat Work Done <br /> l' ` <br /> Approximate Depth a <br /> k DESTRUCTION OF WELL: J, <br /> ,,Well-Diameter <br /> 6 Describe Material and Procedure <br /> t a <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 /> l r 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 Paws of California." <br /> r Contractor's hiring or s ;contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> ct to workman's compensation laws of California." <br /> permit is is ued, I employ persons subje <br /> I will a G sp tion prior to grouting and a final'in <br /> spect' <br /> Title: <br /> Date: � �.j_d __ <br /> Signed X <br /> (Draw Plot Plan on e) <br /> FOR DEP RTMENT, SE ONLY <br /> PHASE I J Date <br /> Application Accepted By / <br /> Additional Comments: ✓ <br /> Pha final spection/� rye) <br /> Phase II Grout Inspection �f �+ �j � <br /> Date /V Inspection By �/" D_ate <br /> t Inspection By h, <br /> I Fee Is Due' 11 ANNUALLY ❑ PER UNIT Ld PER SITE El EACH -❑ January 1 &Received By January 31 T ❑ July t&Received By July 3t <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANA ION DATE DATE REMITTED AMOUNT . <br /> FEE <br /> LESS .I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ii <br /> OTHER <br /> OTHER <br /> �x <br /> Date Receipt No.- Permit No. Issuance Date Mailed Delivered <br /> Received by <br /> L HEALTH PERMIT/SERVICES 1601 E.HAZELTO E•,P.O.Box 2069 STOCKTON,CA 95201..- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTA <br />