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- Applications Will.ae Processed When Submitted roper y _ � <br /> FOR OFFICE USE: APPLICATION <br /> (Fc.r Non-Transferable, Revocabt `Su ble) PUMP&WELL <br /> ENVIRONMENTAL TFi"P IT <br /> WA7 <br /> AMITY 0 ' <br /> (COMPLETE iN TRIPLICATE) t <br /> Application is hereby made to the San Joaquin Local Health District 0ra'OLe nittoconso and/or bs allthework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 168 a�d�the rufes<afld regul + d f the San aquin Local Health District. <br /> Exact Site Address ro A� �44 Qown l <br /> •\`� •(N) \� Phone <br /> Owner's Name It <br />• ' I , <br /> Address ��' City <br /> Contractor's Name <br /> Licenr Business Phone <br /> Contractor's Addressu 6 _� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[) <br /> WELL CHLORINAT N 13 WELL ABANDONMENT <br /> REPLACEMENT ❑ OTHER ❑ PUMP INSTALLATION e PUMP REPAIR <br /> Pit Privy <br />� DISTANCE TO NEAREST: Septic Tank Sewer Lines � <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well 1 <br /> 6 iINTENDED USE TYPE OF WELL <br /> ❑❑ CABLE TOOL INDUSTRIAL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing .�r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal V <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: n Contractor <br /> ' Tye of Pump H.P. <br /> [ ' <br /> 5 PUMP REPLACEMENT: State Work Dane <br /> ❑ State Work Done <br /> PUMP REPAIR: <br /> Approximate Depth <br /> DESTRUCTION OF WELL: i Well Diameter <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 /> 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 /> i <br /> "I certify that in the performance of the work for which t Is <br /> Contractor's hiring or sub-contracting signature certifies the following: <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I will call for a Grout-Inspection prior to grouting and a final inspection. <br /> i, Dale: ' G <br /> r. . <br /> Signed X Title: <br /> {Draw Plot Plan on Reverse Side <br /> FOR DEPARTMENT USE ONLY ter, <br /> I PHASE I 1 o� <br /> Date <br /> Application Accepted By' <br /> Additional Comments: <br /> Plias. II Final Inspection <br /> Ph�srre/II Grout Inspection Date -3 <br /> Inspection By <br /> I vl;� Date Inspection By <br /> �T, <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH C1 January 1 &Received By January 31 El July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> Q/ BASE' EXPLANATION DATE DATE REMITTED AMOUNT <br /> t <br /> FEE y5r Jr <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER r°t -0 <br /> Received by' <br /> Date Receipt No. Permit No sua cc Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009TOCKTON.CA95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PES/SERVICES <br />