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p Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. 017 <br /> FOR OFFICE USE: <br /> APPLICATION <br /> ¢y . For Non-Transferable, Revocable, S 16t){ 1{t <br /> PUMP&WELL All ��rt <br /> ENVIRONMENTAL <br /> ITe.,? <br /> (COMPLETE IN TRIPLICATE) r� <br /> WATER _ �gg1 <br /> Application ishe�9bymade tothe San Joaquin Local Health Districtforaperm nstr d/l rMnstallthewor rein described.This application is <br /> made in compliance with qWi ounty n n c e No. and�i r�s and r ulations of th In ealth Dict z„ <br /> i <br /> Exact Site Address - 7L <br /> Owner's Name <br /> Sp` j. one <br /> -7-2 <br /> Address City— <br /> Contractor's Name 'License# usine Phone <br /> Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation insurance o File With SJLHD? Yes t <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 13 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR CIS V <br /> REPLACEMENT 11 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> - <br /> Sewage Disposal Field Cesspool/Seepage Pit Other LA <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing `U <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> i ❑,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: ❑ State Work Done <br /> PUMP REPAIR: Rll'gtate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> g 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 /> 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 hir' sub-contracting signature certifies the following:"1 certify in the performance of the work for hich this , <br /> permi lss I shall employ p subject to workman's c0mpensati0 s of California." <br /> I w' cal o nspection prior rout' and a final inspection. 1 �/ <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Rev rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ' Date �- 1-97"i <br /> -"i <br /> Application Accepted I3y � <br /> Additional Comments: <br /> Phase II Grout Inspection se RI inai inspection <br /> i Inspection By Date Inspection By <br /> DateBy <br /> d ' -2 Z�� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ❑.EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREM$Tuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> su <br /> Received by Date <br /> Receipt No. Permit N. � issuance Date Mailed Delivered <br /> 9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER 1601 E.HAZELTON AVE.,P.D.Box 2009- STOCKTON,CA <br />