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Applications Will Be Processed When Submitted Properly CarrifflIeW. fSte110O@n I��Application. <br /> I' -Ftt?'"vFFICE USE: _ APP�.It: 41ibJ, <br /> (For Non-Transferable, Revo Suspendabl ) ~ <br /> 1 PUMP&WELL J <br /> ENVIRONMENTAL HE . THP �RII <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY c� OAQUII� LJCTAL <br /> r Application is hereby made to the San Joaquin Local Health District for a permit toconst i+�iPftdDi�e rPlereindescribed.This application is <br /> made in compliance with San Joaquin County Ordir}ante No. i8Cfi2 and the rules and.re Ions of the Sa J uin L a Health District. <br /> Exact Site Address City/Town _ <br /> i A <br /> Owner's Name Phone 6 7 <br /> i Address - City <br /> Contractor's Name License#,,L3 2 Business Phone <br /> Contractor's Address Emergency Phone X66—!—Z: <br /> Is Certificate of Workman's Compensation Ing-rand0e Ing-ranon File With SJLHD? Yes No C <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> r 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 /> r ❑ INDUSTRIAL ❑ CABLE TOOL--- -Dia'of Well'Excavation <br /> ❑ DOMESTIC/PRIVATE DRILLED !Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN f Gauge of Casing "r <br /> ❑ IRRIGATION - ❑-dRAVEL-PACK -----[Depth of Grout Seal - - <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout g <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Sea Installed By: <br /> PUMP INSTALLATION: Contractor �p J <br /> Type of Pump- H.P. f <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> f, PUMP Rt=PAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material arid-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 /> d <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 sighature.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 /> r. I wit II for Grout I pe prior to grou ng and a final inspection. t <br /> Signed X I Title: �-!��v _ Date: <br /> o Ian on ReversdfSi e} ` <br /> FOR DEPARTMENT USE'ONLY ,. <br /> i PHASE C 7 <br /> Application Accepted By t Date tJ�G <br /> �i <br /> Additional Comments: <br /> Pha a II Grout Inspection hase I Final Inspection <br /> Inspection By Date Inspection By 9��ate <br /> ' Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31 <br /> - BILLING REMITTANCE $ REMIT <br /> BASE � � EXPLXNATION DATE DATE .REMITTED AMOUNT DUE - CHECKED <br /> AMOUNT <br /> FEE I v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f - <br /> OTHER <br /> Received by Date - -Receipt No. Permit No. ssuance Dae Mailed Delivered - <br /> APPLICANT—RETUAN-A11 COPIES'TOt-�--ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON.AVE.,P.O.Box 2009' STOCKTON,CA 95207 <br />