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- Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> FOr?:OF,FIC,E USE:, APPLICATION <br /> _ (For Non-Transfe a " vap le) <br /> 4 <br /> "1 VVV PUMP&WELL <br /> ale,- ENVIR L A EALTH PE _ <br /> V <br /> (COMPLETE IN TRIPLICATE) VATIRTM IY 980 <br /> Application is hereby madetotheSanJoaquin Local Health Dis ora t structand/or install theworkherein described.This application is <br /> made in compliance with San Joaqui County Ordinance No. 1862 and the rules attd re�LS of the San Joaquin Local Health District. <br /> Exact Site Address L - 10RQ ;11�� ity/Town <br /> Owner's Name ?Y)AIL- 's i3 H�p`�TH Phoneb 3- P 7 %0 eD 1 - -- <br /> Address L ad d U-1 /V -- City— <br /> Contractor's <br /> ity--Contractor's Name License# /�3 Business Phone 24 S W <br /> Contractor's Address t4 P. dii -27 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ d <br /> WELL CHLORINATION ❑ WELL ABANDONMENT El OTHER El PUMP INSTALLATION El PUMP REPAIR L7 <br /> 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 /> © INDUSTRIAL ❑YCABLE TOOL .w.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 <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 0 tate Work Dane <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth J <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 CA <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 certity 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,.l 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 /> Signed X lCrsn�.l )'??, i��_.��&-� /-� Lr�r���� Title: L e_n/ Dale: G - <br /> li --(Draw-Plot Plan on Reverse Side)4 -- - 1 <br /> f FOR DEPARTMENT USE ONLY <br /> PHASE [ <br /> (11SIV <br /> Application Accepted By --'"`-' Date <br /> Additional Comments: . <br /> Phase II Grout Inspection Ph e I 1 Final Inspection <br /> Inspection By Date Inspection By v ate t <br />� l <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT © PER S1TE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE g REMIT <br /> BASE EXPLANATION AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> IFF PLUS <br /> r PENALTY <br /> OTHER <br /> OTHER <br /> r <br /> Received by Date Receipt No. ", Permit No Iss ante Q to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: r ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />