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11 Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, � �T <br /> FOR OFFICE USE: i� ' APPLICATION <br /> a zTiw- (For Non-Transferable, Revocable,'Suspendable) <br /> I PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) Z�Wel �f 5 g -5 �dJNATER QUALITY <br /> r 2Q— <br /> Application is hereby mad etothe San Joaquin Local Health District fora perm ittoconstruct and/or instal lth.ework herein descrrbed"This ap Iication is <br /> made in compliance with San Joaquin County rdinance No. 1862 and the r les and regulations of the San Joaquin Local Health District. <br /> Exact ite Address �� ! � $ .fC �Jr s � 4. CO"VJ0 City/Town f <br /> Ii ,�••� <br /> Owners Name -s S : $ Phone <br /> Address s ` <br /> c� � City CS, <br /> Contractor's Name ' 11 License# 1U 77-1 Business Phone_ 1- +'X4-7 <br /> Contractor's Address Emergency Phone <br /> ..,As Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes L No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL <br /> 'CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLX6EMENT11 I� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Linesy, Pit Privy <br /> Sewage.Disposal Field C sspool/Seepage Pit Other <br /> E Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL Cy <br /> ❑ INDUSTRIAL ! ❑ CABLE TOOL ..� Dia. of Well-Excavation ) <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing i <br /> ❑ DOMESTIC/PUBLIC I ❑ DRIVEN ` Gauge of Casing K► <br /> IRRIGATION I © GRAVEL PACK Depth of Grout t J <br /> Seal <br /> ❑ CATHODIC PROTECTION II ❑ ROTARY <br /> .,; Type of Grout <br /> ❑ DISPOSAL ❑ OTHER °' F Information V! <br /> © GEOPHYSICAL I } -OtherSurface'Seal.lnstalled By: <br /> PUMP INSTALLATION: I Contractor / , 412I <br /> Type of Pump 'woe ►/ / H.P. `2 /> fill <br /> PUMP REPLACEMENT: ©State Work Dorso• <br /> PUMP REPAIR: State Work Done - C� <br /> DESTRUCTION OF WELL:4 :Lf <br /> il. Well Diameter � _ Approximate DepthI O'i� <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, 1 <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 in the performance of the work for which this <br /> permit is issued, I shall employ persons suMct to workman's compensation laws of California." ' <br /> I w I tail for a Grout In t on ri grout' g and final inspection. <br /> Signed^ rtle: <br /> Date: F <br /> I� (Draw Plot Ian on Reverse Side) <br /> I� FOR DEPARTMENT USE ONLY <br /> PHASE I II z <br /> 4 <br /> Application Accepted By Date 2?� <br /> Additional Comments: <br /> Phase If Grout Inspection Phase III f=inal inspection <br /> Inspection By I` Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION A <br /> :1 DATE DATE REMITTED MOUNT DUE CHECKED <br /> - <br /> AMOUNT; <br /> FEE <br /> LESS <br /> PRORATION II, <br /> PLUS <br /> PENALTY <br /> ` IISOTHER <br /> O!`�HER <br /> by Date ��. =i';.fleceipt No. Permit No, Iss tice ate MailedDelivered <br /> ETURN ALL COPIES TO:'"` ENVIRONMENTAL HEALTH PERMITlSERYICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />