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APPI <br /> Ica ons Will-B6 Processed When Submitted ProperiY Completed: Be Sure To Sign The plication. -A@ <br /> FOR OFFICE USE: � <br /> r '" APPLl.CATlON' r y <br /> (For Non-Transferable, Revocable, Suspendable) <br /> -•:,: . ��` - & <br /> ENVIRONMENTAL HEALTH PERMIT PUMP WELL <br /> (COMPLETE IN TRIPLICATE) �O �C �� r�� HATER QUALITY Z(�-_ <br /> madeAppli <br /> ncom hereby made totheSanJoaquinLocal HealthDistrict fora permittoconstruct and/or install thework herein described.This application is <br /> made In comaiapcQ/wiith San Joaquin County Ordinance No. 1862 and the rules and regulations of the San o quln oval Health District. <br /> Exact Site Address t r^ I- r� ^> <br /> City/TownR <br /> Owner's Name qtr l f <br /> Address ( Phone &'2-L <br /> + r City �[sr. <br /> Contractor''s Name License# �(1�]—Business Phone_ � 3 <br /> Contractor's Address d Emergency Phone �f TZ- f <br /> Is Certificate of Workman's Compensation nsurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -� <br /> WELL CHLORINATION ❑ _. WELL ABANDONMENT ❑ OTH RX PUMP INSTALLATION 11 PUMP REPAIR❑ _ <br /> i REPLACEMENT❑ ' f 11ol� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines yvG ter.. <br /> I Pit Privy <br /> Sewage Disposal FieeJd Cesspool/Seepage Pit Other <br /> r Property Line r Private Domestic Well :r!! — Public Domestic Well <br /> I INTENDED USE TYPE OF WELL r <br /> I's ❑`INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED �.. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Dia, of Well Casing <br /> + <br /> Gauge of Casing <br /> ❑ IRRIGATION ❑ <br /> GRAVEL PACK Depth of Grout Seal a <br /> ❑ CATHODIC PROTECTION ❑.ROTARY Type of Grout��-&.. 4R <br /> ❑ DISPOSAL OTHER h + <br /> �e Other Information <br /> ❑ GEOPHYSICAL &41q r_ Ar"W/41 Surface Seal Installed 8y: <br /> PUMP INSTALLATION: Contractor <br /> f <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done 44 <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximateepth v'e <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:"I certify that in the performance of the work for which this `ll <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will fora Grout Ioe s ction prior to grouting and a final inspection. fir] <br /> Signed X0 <br /> Title: r, 0 <br /> Date: <br /> raw Plot Plan on Reverse Side} <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE I - <br /> F3 <br /> Application Accepted By <br /> Additional.Comments: <br /> Da#e <br /> se 11 Grout inspection t� Phase III Final Inspection <br /> Inspection 8 Date -BCS Inspection By <br /> Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By January 31 ❑ July 1 S Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ EAN <br /> REMIT <br /> DATE DATE REMITTED CHECKED , <br /> FEE AMOUNT ,#t <br /> LESS :- 'S <br /> PRORATION •� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 4757 <br /> Received by •-, Date Receipt No. Permit No. fssua a Date <br /> Mailed- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.-Box 2009 STOCKTON,CA 95201 <br />