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Appli nsli O s s e mitted Properly Completed. Be Sure,To"Sign The Application. I u <br /> FOR OFFICE USE: � -=� PPLICATION <br /> (For Non r sferable, Revocable,Suspendable) PUMP&Wl LL , <br /> AUG 13 189VIRONMENTAL HEALTH PERMIT' ' N <br /> E <br /> WATER QUALITY. <br /> (COMPLETE IN TRIPLICATE) tt <br /> Application is hereby made toth 'rfJoa W111.0WATER <br /> F�ii�trictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joa�i Lhty%51 04D. 1862 and rules and regulations of the.San J qui Local Health District. <br /> s'� / i [� -r.J �'--�- City/Towna :� <br /> Exact Site Address <br /> Owner's Name Phone <br /> Address S�C'1 �, City <br /> Contractor's NameLicense#/C�.3 7 3 Business Phone 3 C - 3'� <br /> Contractor's Address f_ <br /> Emergency Phone "TLC" IF6 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes k— No ��- <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ ,may <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �J <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 �D /1�� <br /> Type of Pump , :r_ H.P. 7 <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 /> 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 Wilk II/f _a Grout I e_ction prion to grouting and a final inspection. <br /> Signed X �` E-�✓ itle: Dater r <br /> (Draw Plot Plan on ReversAide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE! 1^Q Q <br /> Application Accepted By <br /> Additional Comments: <br /> Pi sal o ction - ase Final Inspection ZI <br /> Inspection By - D�te Inspection 87Dates r' <br /> d �► .� <br /> Fee Is Due: 11 ANNUALLY ❑-PER-tJNff ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 3-1,.,/ <br /> REMIT <br /> !_BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ,h <br /> DATE DATE REMITTED AMOUNT. . <br /> FEEex <br /> LESS ' �- 4 `` •'' y - <br /> PRORATIONPLUS <br /> s- t <br /> PENALTY <br /> OTHER ( <br /> 1 � c <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is ante❑ to I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />