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Appl �i n§.�Vilft6-0rocessedWhe mitted Properly Completed. Be Sure To Sign The Application. <br /> FOR;�EFICF USE: PPLICATION <br /> -" NOV 3 lWhon-Transferable, Revocable, Suspendable} <br /> E NMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) S�� :11.1t� <br /> W�ALTH DISTRICT WATER QUALITY <br /> Application is hereby made to theSa'n oaquinLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is <br /> made in compliance with San Joag3in�County Ordinance No.1862 and the rules and regulations of the SapJoaquin Local Health District. <br /> Exact Site Address_��/`f Z 1461 - - City/Town -� ,6,,_�S33o LL j <br /> _ .was te ) <br /> I <br /> Owner's Name _�L.+�Q- Phone `xl <br /> Address :I City Ica 3 3 0 <br /> Contractor's Name 43LC License# Business Phone / d <br /> Contractor's Address J? U 2 - Emergency Phone � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Y No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS d <br /> REPLACEMENT❑ IM <br /> z <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines —Pit Privy <br /> Sew a.i:ge Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE i TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Weil Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 2 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION I ❑ ROTARY Type of Grout <br /> ❑ DISPOSALElOTHER Other Information <br /> ,/� _ate <br /> 13 GEOPHYSICAL '` urface Seal Installed By: I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ]d ) <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 <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin County 7T <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or Ilcensed h gent'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 forwhich this <br /> permit is issued, I shall 6 mploy persons subject to workman's compensation laws of California," <br /> I will call for a Grout In Ilpection prior to grouting and a final inspe tion. <br /> Signed X J1 + Title; Date: C1 a <br /> �[ (Draw Plot Plan on Re rse Side) <br /> FOR DEPARTMENT USE ONLY � <br /> PHASEI 1 <br /> Application Accepted By Date <br /> r <br /> Additional Comments: <br /> Phase'lll Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date 4911 <br /> Fee Is Due: ❑ ANNUALLY '110 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> it BILLING REMITTANCE $ REMIT t <br /> - BASE II EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> I` AMOUNT <br /> FEE J-9— <br /> LESS' <br /> PRORATION <br /> PLUS I� } <br /> PENALTY <br /> OTHER <br /> OTHER IIID <br /> Received by Date ,I�. Receipt No. - Permit No. P55uahce Date _ Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 101 E.HAZELTON AVE.;P.O.Bos 2009 STOCKTON,CA",IQ_] f <br /> I <br />