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- _ . .. rr : _. ...... <br /> _ Applications Will Be Processed When Submitted Properly om <br /> FOR OFFICE USE: APPLICATION J j <br /> kk (For Non-Transferable, Revocad fe PUMP&WELL <br />� - <br /> ENVIRONMENTALT <br /> L ERMI T , ��isWATERQE� <br /> (COMPLETE IN�,TRIPLICATE) j T rein described.This application is <br /> Application ishf�"rebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstruc and/orinstaL�lth uLocal <br /> a�f]istrictt.. <br /> j <br /> made in compiiance with uin County Ordinance No. 1862 and t rules and reg`ula4tor " iT_1� <br /> r Exact Site Address <br /> iV /l—� cJ G Phone <br /> Owner's Name f^ TT <br /> Address k/I ��� City ,� <br /> L '-9 (� !`�? License# Business Phone ' <br /> Contractor's Name �� 7_ <br /> ' � � J�1>� S Emergency Phone <br /> Contractor's Address No <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT 13 OTHER 11 PUMP INSTALLATION 13 PUMP REPAIR <br /> ii <br /> REPLACEMENT❑ <br /> 11 <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field cesspool/Seepage Pit Other <br /> Pr`perty Line Private Domestic Well Public Domestic Well <br /> INTENDED USE ! TYPE OF WELL <br /> ❑ INDUSTRIAL - yi. 0 CABLE TOOL Dia: of Well Excavation <br /> ❑ DOMESTIC/PRIVATE !� ❑ DRILLED Dia. of Well Casing <br /> ©�Y5OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ,d IRRIGATION I� ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ,n, ❑ ROTARY Type of Grout <br /> I ❑ <br /> DISPOSAL <br /> 11 OTHER Other Information <br /> El GEOPHYSICAL II Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> I 11 State Work Done ' <br /> ° PUMP REPLACEMENT: <br /> ! 5State Work Done <br /> PUMP REPAIR: ' <br /> DESTRUCTION OF WELL: <br /> C Well Diameter Approximate Depth <br /> Describe Material and Procedure _•- <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> nsed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> Nome owner or lice <br /> l is issued, I shall not employ any person in such manner as to become subje to workman's compensation laws of California." <br /> Contractor's hi r sub-contrac' signature certifies the following:"I ify that in the performance of the work forwhich this <br /> per s Is I hal emplo person subject to workman's compens ion laws of California." <br /> I 1 ill 1 s ectio ,prior groutingand a final ins <br /> � 73 <br /> Signed X �1 Title: Date: <br /> i (Draw Plot Plano everse Side) <br /> f <br /> B <br /> Ij FOR DEPARTMENT USE ONLY <br /> Ot <br /> PHASE I I4 .�„ Date R` �v <br /> Application Accepted By <br /> FAdditional Comments: ` <br /> Phase It Grout Inspection Ph se Ill Final Inspection <br /> Inspection ByL� Date Inspection By Date <br /> _�t <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 B Received By Juty 31 <br /> REMIT <br /> EXPLANATION BILLING REMITTANCE $ 'AMOUNT DUE CHECKED <br /> BRSE 7x( DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS I� <br /> PRORATION _ <br /> PLUS I! <br /> PENALTY <br /> li <br /> OTHER <br /> OTHER <br /> ;i <br /> Im 3 i 3g <br /> N o a, <br /> Received by <br /> ,!pale Receipt No. Permit No. suance a e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERµITlSERYICES 1601 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 952 <br />