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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> i4OR ONCE USE: APPLICATI � <br /> (For Non-Transferable, a s1r Iel► PUMP&WELL <br /> J ENVIRONMENTAL LTH PERMIT q <br /> (COMPLETE IN TRIPLICATE) / lr50� r ATE L TY JAN o 1982 <br /> Application is hereby made to the San Joaquin LocalHealftPDistrict a &nit to construct and/orinstal t rKk herein described.This application is <br /> made in compliance with San Joaquin County Ordinance o.1862 and the rules e �o quln Local Health District. <br /> Exact Site Address Y �"�"' •� i _ . f <br /> Owner's Name i <br /> r, „ Phonec: <br /> i Address 1fll l 4(- City " <br /> Contractor's Named License Business Phone' <br /> Contractor's Address _ � S'?7 Emergency Phone <br /> is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No 013 <br /> TYPE OF WORK (CHECK):' NEW WELL DEEPEN ❑ - RECONDITION❑ '-' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <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 /> ❑ DUSTRIAL ❑ CABLE TOOL - e Dia. of Well Excavation - <br /> u 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: r <br /> PUMP INSTALLATION: Contractor <br /> Type-- <br /> yppee of Pump H.P. <br /> \ <br /> ` 0PUMP REPLACEMENT: State Work Done ° " <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: :Well Diameter Approximate Depth <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 lollowing 'Tcertify that in the performance of the work for which this permit <br /> f is issued, I shall not employ any person in.such manner as to become subject to workman's compensation laws of California." <br /> o 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 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 �_rc �• r�f .G s� ��Tiile: Date: <br /> Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I , <br /> Application Acceptedy <br /> dzi <br /> ° Date 41 <br /> Additional Comments. <br /> Phase 11 Grout Inspection r - se III Fina <br /> Inspection By Date Inspection B ate <br /> Fee IS Due: 13ANNUALLY ElPER UNIT 91IR SITE 11 EAC ❑ Januar Received By Januar ❑ July 1 &Received By July 31 . <br /> REMIT <br /> BASE EXPLANATION 13ILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> }_ DATE DATE REMITTED AMOUNT <br /> ;s <br /> FEE � "� C.x <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ••f <br /> OTHER „ <br /> OTHER <br /> Received by - Date- - Receipt No. Permit No. Ilssuanhe Date Mailed Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />