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., i+Nilutmonswill BeProcessedWhen Submitted Properly I e�1r <br /> +9 N.Th �r <br />� <br /> FOR OFFICE USE: APPLpCAT,+ L:7 plication. <br /> (For Non-Transferable, Revoc <br /> ENVIRONMENTAL HEALTH P -0 1979 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Appiication is hereby made to the San Joaquin Local Health Dist riot fora permit to cons nr �1 <br /> made in compliance with San Joaquin County Ordinance No. 7862 and the rules an a� ir� �rlc.,e � �ein described.This application is <br /> Exact Site Address �O�s�f�+��aR �quin Local Health Di <br /> rt/ strict. <br /> City/Town <br /> Owner's Name <br /> Address Phone <br /> Contractor's N me <br /> Contractor's Address <br /> License# /� 3 Business Phone_ <br /> — <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHDmergYes Phone , <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ Yes No <br /> WELL CHLORINATION 11 WELL <br /> DESTRUCTION❑ <br /> WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION W PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Other <br /> INTENDED USE Public Domestic Well <br /> 11 INDUSTRIAL TYPE OF WELL <br /> ❑ CABLE TOOL �� .. <br /> ❑ DOMESTIC/PRIVATE � Dia, of WeII,Excavation zr,b <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> El IRRIGATION Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> El DISPOSAL Type of Grout <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor Surface Seal Installed By: � <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work DoneQ <br /> PUMP REPAIR: 0 01. <br /> ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <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 an " <br /> P y y 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 4 <br /> p y persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> r <br /> Signed X -- LC?.aA_� Title: <br /> (Draw Plot Plan on Reverse Si e) Date: �— <br /> PHASE I 'FOR DEPARTMENT USE ONLY I <br /> Application Accepted By y 7 <br /> Additional Comments: Date <br /> 1 <br /> Phase u I ection <br /> Inspection By Date Inspection By Phase III a speaIe n <br /> r <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BELLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> AMOUNT <br /> LESS ✓ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER h <br /> OTHER <br /> �q—� <br /> Received by Datei <br /> Receipt No. Permit No. Issua ce Da <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .Box 2 Delivered <br /> ' .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />