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=� .. <br /> k. Applications Will Be Processed When�Sabrl�aited Properly Completed. BeSure oSign <br />._ ' FOR OFFICE USE: APPLICATION <br /> I (For Non-Transferable, Revocable, Suspendable) <br /> Y PUMP&WELL W <br /> ENVIRONMENTAL HEALTH PERMIT <br />" WATER QUALITY 6 <br /> 1 (COMPLETE IN TRIPLICATE) <br /> District for a permit construct and/or install the work herein described.This application is <br /> Application is hereby made tothe San Joaquin Local Health <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joagui Lo I Health District. <br /> Exact Slte Address_"OG ' ��"� City/Town <br /> �1 Phone <br /> Owner's Name &s V <br /> Address M City <br /> Contractor's Name License#19j—%ZSR Business Phone �6 <br /> 1- --74AC <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> t WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 19 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 <br /> ❑ CA13LE TOOL Dia. of Well Excavation <br /> A 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 Irys3alled By: O <br /> 1 PUMP INSTALLATION: Contractor c�t�b resp g, <br /> y Type of Pump S'd,L did <br /> __ ��w�,, N.P. <br /> PUMP REPLACEMENT: id State Work Done ?UA2 d- //��—fgL��I <br /> PUMP REPAIR: <br /> ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �1 <br /> Describe Material and Procedure <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 /> Home owner 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> r - <br /> I wil call fora Grout Inspect' ri to ng and a final inspection. <br /> I It- <br /> Signed X sop I itte: Date: <br /> (Draw Plot la on Reverse Side) <br /> r FORD PARTMENT USE ONLY <br /> K <br /> PHASE I <br /> Date <br /> Application Accepted By <br /> i Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <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 /> REMIT <br /> I BASE - EXPLANATION BILLING REMITTANCE $ AMOUNT DUE - CHECKED <br /> F DATE DATE REMITTED AMOUNT <br /> r FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY n <br /> �r^ <br /> OTHER <br /> OTHER <br /> —7&1_13 to tt <br /> Received by Date Receipt No. Permit No. Issuance Male Mailed Delivered <br /> [- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />