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.., <br /> Applications Will Be Processed When SubmittedPro k <br /> I:FE: I f APPLICATION <br /> FOR OFFIC€= <br /> .' rn lA�` (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> I (COMPLETE IN TRIPLICATE) <br /> in Local Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made tothe San Joaqurules and of the San Joaquin Local Health District. <br /> I, made in compliance with San Joaquin County Ordinance No. 1862 and the <br /> k` Exact Site Address e- ` If Me A, gjes¢ 1rov 4c! ,G�a�r el L;L_, City/Town <br /> rrh /t �° •a�1 Phone 'pll 3 <br /> Owner's Name ity11 "``- <br /> r Address If 2. —Tek?rr <br /> License# /�1.3 7 L� Business Phone <br /> Contractor's Name " <br /> Contractor's Address Emergency Phone <br /> I, No <br /> Is Certificate of Workman's Compensation Insurance on ,Ile With SJLHD? Yes X <br /> TYPE OF WORK (CHECK): NEW WELL 101 DEE EN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT <br /> TALLATION❑ PUMP REPAI <br /> i. T ❑ OTHER ❑ PUMP INS <br /> R <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> I Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> t <br /> INTENDED USE TYPE OF WELL <br /> t. Dia. of Well Excavation <br /> 11 INDUSTRIAL f ❑ CABLE TOOL <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> f ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> GRAVEL PACK Depth of Grout Seal <br /> ® IRRIGATION <br /> 13CATHODIC PROTECTION ❑ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Ind 8y: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done .. <br /> State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCT10N OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> 4 <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 for which this ^ <br /> permit is issued; I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Groutjps ec'on rio to gr ting ant4a final inspection. f� <br /> Signed Title: <br /> Date: �'v <br /> (Draw PI Plan on Reverse Side) <br /> f <br /> k FOR DEPARTMENT USE ONLY r <br /> k PliASE I <br /> �1�9.a_L ©� Date O'�C�b <br /> Application Accepted By <br /> Y Additional Comments: <br /> Phase 11 Grout Inspection Phase Ill F'fif Inspection <br /> Date <br /> Inspection By Date <br /> Inspection By �1 <br /> Fee Is Due: [3 ANNUALLY ❑ PER UNIT F-1PERSITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received July <br /> 3} <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> M <br /> FEE <br /> t LESS !1 <br /> I PRORATION /� U <br /> PLUS t <br /> PENALTY <br /> OTHER <br /> OTHER [ 41y <br /> r Date �# Receipt No. Permit No <br /> Is uance ate Mailed Delivered <br /> Received by <br /> s APPLICANT—RETURN ALL COPIES to: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELSON AVE.,P.O.Box 2009 STOCKTON,CA:95201 <br />