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°- ;� ppiicatlons Will Be Processed When Submitted Properly Completed. Be Sure Tp, ation. a <br /> FOR 9E: , APPLICATION _(For Non-Transferable, Revocable, ej �)U: J j <br /> s- ENVIRONMENTAL HEALT RMIT 1 1g�o PUMP&WELL <br />-I (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> A15plicationisherebymadetotheSanJoaquinLocalHeaith'Districtforapermittoconstructand/or install ti�ewo'N 'Tr�erin_d�scribed.This application <br /> j ? <br /> made in comply rice with San_Joaquin Cou ty Ordinance N . 1862 and the ul and regulat'I�erp�f, tl`ie�an d�iq&htL`ocal Health District., <br /> Exact Si Address Al CiTr4n • <br /> r <br /> mow,. <br /> Owner's Name Phone <br /> Ada ss Ra" 6 �3 - city <br /> Contractor's Name -IACLicense#�_.�_�1_2_L_ Business Phoneto <br /> Contractor's Address -Z3n - � Emergency Phone V6 C`74 � 1 <br /> Is Certificate of Workman's CompensationIn urance on File With SJLHD? Yes _ _-S)TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> F WELL CHLORINATI N ❑ WELL ABANDONMENT El OTHER 11 PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT'S U Q� <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 /> �-fND"l STR1iaL' ❑ CABLE TOOL Dia. of Well Excavation <br /> B'DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN' TGauge of Casing' <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 13-,ROTARY Type of Grout <br />'y ❑ DISPOSAL �' �� ❑ OTHER Other Information <br />'w f GEOP4SICAL ,.�surtace Seal Ins Iled By: <br /> 1 PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. � r <br /> PUMP-REPLACEMENT: f�� �� 'State Work Done <br /> i PUMP REPAIR: (/ ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate_Depth <br /> Describe Material and Procedure T — <br /> k l 1 <br />' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> o`3inaTrcesfstate-iaws-and rules.and regulations of the San Joaquin Local Health District. _ <br /> Home owner or licensed agent's signature certifies�ihe lollovrin`g:'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 Catifornia_"'- ,... � <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"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 w' Calr a Gro�IpeCtlon �foouting and a final inspe <br /> Signed X Title: Date: l ^�6 <br /> —(Draw Plo an on-Reverse de) A <br /> i ; FOR DEPARTMENT USE ONLY ¢ <br /> PHASE I L, 4 <br /> Application Accepted By 1 Date y <br /> Additional Comments: _ <br /> Phase 11'Grout Inspection ��Ph se III Final 1 spection <br /> Inspection By Date Inspection By Date <br /> -Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER-SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 �^ <br /> BELLING REMITTANGE $ REMIT <br /> BASE EXPLANATION DATE - GATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> Spt7 d l <br /> FEE <br /> i <br /> LESS a <br /> PRORATION i <br /> P PLUS 44 <br /> ' PENALTY - <br /> OTHE4- <br /> OTHER-, <br /> Received by Date Receipt No. ermII No- IssuiIince Dae Mailed Delivered � 1 <br /> • APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 _ <br />