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APR ti ..STIPEe&c4ss6W ubmit ted Properly Completed. Be Sure To Sign The Application. <br /> FQIR OFF�-CE USE: J APPLICATION <br /> 19Rr N n- ransferable, Rev6i>able, Suspendable) PUMP&WELL <br /> SEP J ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE$AN jo! 01,JIN L00 WATER QUALITY <br /> Application is hereby made tothipfLaALdf4 i r[yaTI RQttiDistrict for apermit toconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Jo uln Lo I Health District. <br /> Exact Site Address City/Town <br /> �. - n „t��� .. Phone <br /> 13 J'-- <br /> Owner's Name ri4- -�'-- —✓ ; <br /> Address G' City q _ <br /> Contractor's Name 9 %- License# �� '� Business Phone ��G- / �`' <br /> Contractor's Address r� Emergency P>06" <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No -- <br /> TYPE OF WORK (CHECK): NEWVEL,L❑ 'DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ r <br /> WELL CHLORINATION 13 WELL ABANDONMENT E] OTHER 13 PUMP INSTALLATION 13PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal FieldCesspoollSeepage Pit Other <br /> I Property Line Private Domestic Well Public Domestic Well <br /> TENDED USE TYPE OF WELL - <br /> ❑ IN USTRIAL .�. ­'❑ CABLE TOOLDia of We li Excavation <br /> D MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ D MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IR IGATION 13 GRAVELPACK Depth of Grout Seal <br /> ❑ C THODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ SPOSAL ❑_ OTHER Other information <br /> ❑ EOPHYSICAL I lr`. Surface Seal Installed By: <br /> PUMP INSTALLATION: '"" Contractor <br /> e <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done 41 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> !. ,. Describe Material and Procedure <br /> I herebycertify that I have prepared this application and that the w <br /> ork 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 /> _ _ w _.� <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 inrthe 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 Grout Inspection prior to grouting and a final inspection. <br /> F Title: `� r-�p� Date: _ 7 "'3. , <br /> Signed X — _ <br /> * *' (Draw Plot Plan on Reverse Side) - - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I _: <br /> - Date <br /> Application Accepted By <br /> Additional Comments: <br /> ,r Phase II rout Inspection .P a III Final Inspection <br /> Inspection By Date Inspection By - e <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH! ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITJuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> j, PENALTY - <br /> OTHER <br /> OTHER <br /> Receivetl by Date Receipt No. a it No. Is uance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />