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Applications Will Be Processed When Submitted Properly Complete , e jyr�(To4g�igr THIA"Ic�tgo�� <br /> FOR.oOFFICE USE: APPLICATION JJ�� <br /> (For Non-Transferable, Revocable, Susp ble) I <br /> E <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH P MITDQ <br /> OCA 24 1979 <br /> WATER QUALITY LOCAL <br /> (COMPLETE IN TRIPLICATE) c n <br /> 10A'R 1.�N T <br /> Application is hereby madetothe San Joaquin Local Health Districtforapermittoconstruct and/or al - I, �sis@lkcFibed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations oft an Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> 7 <br /> Owner's Name Phone D& 7" <br /> Address t City—d-41se'yi 0-- <br /> Contractor's Name 7Z S nJ License# ,2790lp Business Phone 899-,2.207 <br /> Contractor's Address Emergency Phone -S,qmz <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 41No <br /> TYPE OF WORK (CHECK): NEW WELL C1 DEEPEN 11 RECONDITION 1_7 DESTRUCTION❑ }� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <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 <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 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: IffState Work Done of-,4 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 thework forwhich 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca r a Grout Inspection prior to grouting and a final inspectio - <br /> Signed X Title: ___�/1.��//ss+�� Date: �C <br /> (Draw Piot Plan on Reverse Side) <br /> FO DEPART ENT USE ONLY <br /> PHASE <br /> Application Accepted By Date �y <br /> Additional Comments: <br /> Phase II Grout Inspection �9/ Pha III Fin Inspection <br /> Inspection By Date l+"� Inspection By Date// -� 7� <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH © January 1 &Received By January 31 ❑ July 1 &Received By.}uly 31 <br /> BILLING REMITTANCE $ REM4T <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> /v Zy Id-,S,5 0 y ���� <br /> R ceived by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,c 1 <br />