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Applications Will Be Processed When Submitted Prop erlyoj Iete+d.,aerSuroi nTheApplication. <br /> .FOR-OFFICE USE: APDL{ �3rtll 1 9 ]( <br /> (For Non-Transierable, c e, uspendab e) h PUMP&WELL <br /> ► J <br /> ENVIRONMENTA AL3ff�AIt81 <br /> r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Hoalth istrictfora permit t�Astr}{>t d/ s 1 r.Urk herein described.This a plication is t <br /> made in compliance w�lrl lo�qut u inanc d J�qqE(Ajetim�[t1LT ui I st ct. <br /> Exact Site Address Q/ `/ City/Town <br /> PlAe lei <br /> Owner's N B � <br /> Address <br /> Contractor's Name � Licee# Business Phone y <br /> Contractor's Address _ ' <br /> c � si Emergency Phone �•xaf <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 /> WELL CHLORINATION ❑ WELL ABANDONMENT 11 OTHER 6P� PUMP INSTALLATION ❑ PUMP REPAIRL <br /> REPLACEMENT❑ OQ <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 ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ 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 C <br /> ❑ GEOPHYSICAL e—Surf ce al Install y: } <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br />` PUMP REPLACEMENT: <br /> ❑ State Work Done ' r <br /> PUMP REPAIR: ❑ State Work D e <br /> DESTRUCTION OF WELL: Well Diameter p oxi ept <br /> Describ Procedure <br /> I hereby certify that I have prepared this application and that 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 /> 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 n oy any person in such manner as to become subject to workman's compensation laws of California." t� <br /> Contractor's <br /> hi g r sub-contras ' gnature certifies She iollOwing:"I y that in the performance of the work for which this �] <br /> permit ' shall Ill ersons subject to workman's compen n 1a of California." <br /> I wil call o pection or t a final inspect' tai{ <br /> Signed X 1 Title: Date. <br /> _ .�_ —(Draw Plot Plan on everse Side)� <br /> _ 3 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase if Grout Inspection Phase Ill Final Inspection Y <br /> Inspection By Date Inspection By Date ! <br /> , s <br /> Fee Is Due: ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 S <br /> l <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 1 <br /> FEE F! <br /> LE$5 [ 7 /OYr-►`dt '� /l"[ �jGtJ f J'1! <br /> PLUSPRORATION ��1V PJ04i +-ed <br /> PENALTY J <br /> R L V <br /> OTHER <br /> OTHER / t q� O "'�!r D4U� / r u.L ✓� . <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />