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v Applications Will Be Processed When Submitted Properly Completed.� `bA <br /> uji l�Fie pPflC�ti�r�. I . <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) FEB 11 198(� <br /> `PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT r� <br /> (COMPLETE IN TRIPLICATE)✓r £ �7CT T z Sys ATER QUALITY SM J0 '1(`!�V �u%[�+� <br /> Application.isherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinsa the workl'ier�inPdOcFibed.This application i's <br /> made,in compliance wi h San oaquin o}�f'ty 0 dinan No. 862 and th rut an regula ' ns of the San Joa uin Local Health District" o <br /> Exact Site Address r`, pa �yy�t ���j t / ity/Town <br /> Owner's Name 1, <br /> Phone <br /> i <br /> Address City <br /> Contractor's Name _ License# .5.� JiB <br /> ,__ _ usiness Phone <br /> Contractor's Address Emergency Phone If r <br /> Is Certificate of Workman's Compensation Insurahce on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLIX DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 1:1PUMP INSTALLATION. PUMP REPAIR[3 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: - Septic Tank ��( Sewer Lines Ql Pit Privy <br /> Sewage Disposal Field - Cesspool/Seepage Pit Other <br /> Property Line ,-_ Private Domestic Well ' — Public Domestic Well <br /> 4 INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia" of Well Excavation <br /> DOMESTIC/PRIVATE KDRILLED Dia. of Well CasingChin <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal 1 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL I Surface Seal Installed By: I Ir L <br /> PUMP INSTALLATION: Contractor&zae1C_ �&ewr <br /> Type of Pump � F� p �?" H.P. / <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑.State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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." i <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I sh II employ persons subject to workman's compensation laws of California." <br /> G Ins ection prior to grouting and a final.inspeciii <br /> c tee, yy <br /> Signed X G Title: " Date: <br /> (Draw Plot Plan on Reverse Sid <br /> _ I <br /> I F RDE ARTME T USE ONLY <br /> PHASE j <br /> Application Accepted By 1 Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P as III Final Inspection <br /> Inspection ByC.-��A Inspection By Date L1 <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PE9 UNIT PER SITE ❑ EACH' ❑ .January 1 &Received By January 31 + ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT OUE CHECKED - <br /> AMOUNT <br /> FEE i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY l <br /> OTHER <br /> OTHER <br /> � s <br /> Receivedby - Date- Receipt No. P fit NoI 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 II <br /> I <br />