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Applications Will Be Processed When Submitted Proper) , ,JeBO� 7?51 toTneApplication. <br /> FOR OFFICE USE: APPLICAT ` Q <br /> (For Non-Transferable, Revo Suspendable) <br /> PUMP&W Ll. <br /> ENVIRONMENTAL HEALTH 1979 <br /> (COMPLETE IN TRIPLICATE) WATER QUALIT <br /> Application is hereby made to the San Joaquin Local Health District for a permit to co§ANt aQAQ(1PJfJ tle�_r herein described.This application is <br /> made in compliance wl h San Joaquin County Ordinance No. 1862 and the rules an,HFAja��fs 1jn� ry, uin Local Health District. <br /> Exact Site Address -� / - I�[I City/Town C• C✓ <br /> Owner's Name _- Phone <br /> Address City / <br /> Contractor's Name License# 1i� 3 Business Phoney�6- -x-S <br /> Contractor's Address . 7_ rT f� _A Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ,�,/� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRta <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 S <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing S <br /> ❑ OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing v <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information _917 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. , <br /> PUMP REPLACEMENT: ktate Work DonePUMP REPAIR: tate 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 /> 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 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 <br /> Inspection prior to grouting and a final inspection. -,q <br /> Signed X t✓lfly^' Title: )122 a Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPARTM NT USE ONLY <br /> PHASE ] 17r <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspecti <br /> Inspection By Date Inspection By ate 9 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN4T ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 911AL <br /> .LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER r�.�1 <br /> OTHER X17 <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 85201 <br /> 4 <br />