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ApplicationsWi a prfi kc ss�dtheA.Sy�mitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: ,i ' :1 ?�q I�ICATION <br /> (For Nona r sire able, Revocable, Suspendabie) <br /> Q CrONIIREN7AL PUMP&WELL <br /> t HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made tothe 5 qujriL6-6-hfH-0aIffi,PisttjEtforapermit toconstruct and/or instal lthe work herein described.Thisapplication is <br /> made in compliance with San 3�qui� <br /> Exact Site Address unt�r:'QrCjir�a Ice iV2.1 862 and the rules and regulations of the San Joaquin Local Health District. <br /> Owner's Name <br /> City/Town <br /> ��,� <br /> Address 3.37 Phone <br /> Contractor's NameCity <br /> L` License# .?� 3 <br /> Contractor's Address /�•�* Business Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD�ergYes Phone <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ Yes No <br /> WELL CHLORINATION ❑ RECONDITION El DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ ,,,/ <br /> REPLACEMENT❑ PUMP REPAIRIeJ <br /> DISTANCE TO NEAREST: Septic Tank <br /> . Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> INTENDED USE <br /> Property Line Private Domestic Well Public Domestic Well Other <br /> TYPE OF WELLIlt � <br /> DUSTRIAL ❑ CABLE TOOL <br /> )DISPOSAL <br /> MESTIC/PRIVATE Dia. of Well Excavation <br /> MESTIC/PUBLIC ❑ DRILLED Dia. of Welf Casing <br /> ❑ DRIVENGauge of Casing <br /> IGATION ❑ GRAVEL PACKTHODIC PROTECTION ❑ Depth of Grout Seal <br /> ROTARY <br /> Type of Grout <br /> ❑ GEOPHYSICAL ❑ OTHER Other Information <br /> PUMP INSTALLATION: Contractor Surface Seal Installed By: <br /> Type of Pump H.P. W <br /> PUMP REPLACEMENT: E3 tate Work Done <br /> PUMP REPAIR: State Work Done W <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure Approximate Depth <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-1 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 Grout Inspection prior to grouting and a final Inspection. <br /> Signed X o-�r.�-.. � , „ _ <br /> _'Title: _ Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY Application � }- <br /> Accepted By <br /> Additional Comments: Date <br /> Phase li Grout Inspection <br /> Inspection By tvv P s II Final peclion <br /> Date Inspection B <br /> Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE <br /> ❑ EACH El January 1 &Received By January 31 ❑ July 1 &neceived By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE ^� AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. er A <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITPSERVICES Issuance Oate Mailed ermit No <br /> Delivered <br /> 1601 E.HA2ELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 , <br />