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App1i s� �il� ro' ss�e!Vli�n fitted Properly Completed. Be Sure ToSignTheApplication. <br /> FOR OFFICE USE: PLICATION <br /> N <br /> 14't 1 411 n-Transferable, Revocable, Suspendable) PUMP&WELD <br /> _ - <br /> ENVIR .WENTAL HEALTH PERMIT <br /> Y C"qtr '. Q. <br /> WATER UALITY <br /> (COMPLETE 1N TRIPLICATE) - SAT4 ' t <br /> Appl ication is hereby Made tothe San j& nJAa A9A9istrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County.Ordinance No. 1862 and theles and regulations of the San Joaquin Local Health District. <br /> Exact Site Address =H'1 uleCity/Town L f )m <br /> f r <br /> o <br /> Owner's Name Phone '73 —plc `t <br /> Address ► City Lol9iJ-- .- <br /> Contractor's Name A� uu a_ 4 cxo^� s�^� }-- License#C' 1 Business Phone y <br /> ' Contractor's Address <br /> li ii a Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on ile With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ .- WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ n <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines fit Privy <br /> `r""Sewage Disposal Field -� Cesspool%Seepage AI - Other ....gid <br /> r. <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE 'TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Ex <br /> cavatian <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> Vf DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing , ` r f" <br /> ❑ IRRIGATION U GRAVEL PACK Depth of Grout Seal <br /> y ❑ CATHODIC PROTECTION 0.ROTARY Type of Grout _/fit=2 S� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �!`: a Surface Seal Installed By: <br /> PUMPINSTALLATION: <br /> INSTALLATION: Contractor H P <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done 4 <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 k <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 /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Gr nspectio p for to grouting and a final inspection. <br /> Signed X Title: yf'46SK�^[ tl�aL_ Dater <br /> L_..3 (Draw Plot Plan on Reverse Side) , <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phas, III Final Inspection <br /> Date Inspection By Date <br /> Inspection By 9 <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT El PER SITE ❑ EACH El January 1 &Received By January ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUii <br /> IT <br /> FEE. w <br /> LESS <br /> PRORATION t <br /> -PLUS <br /> PENALTY <br /> OTHER •' <br /> OTHER <br /> Receive by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br />? x APPLICANT—RETURN ALL COPIES TO:- ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 }� <br />