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1 .1c*�Flce usE, APPLIC:A <br /> (For Non-Transferable, Re m I ettQlab ) 1 ' pUMP &WELL <br /> ENVIRONMENTAL H TH�PEF MIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY `JJ 1J <br /> Application d' rsfst tjlth�fr�St �ereindescribed.Thisappticationis i <br /> pP y nt�' <br /> l r <br /> made in compliance with San <br /> /Joa in Count rdinance No. 1862 and the rules ar'�irregul:th j o >? quin cal Health Districtif 0 . Q <br /> Exact Site Address //A�t .— - — E _ �CttttyiTown —. <br /> Owner's Name — — Phone <br /> Address __ D — City — — - <br /> Contractor's Name �klA -< — License##,13.13 Buusiiness Phone�4 <br /> Contractor's Address to ��� — r — — _ Emergency Phone <br /> Is Certificate of Workman s Gompensation Insurance on File With SJLHD? Yes-- No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT G2e OTHER 11PUMP INSTALLATION 13PUMP REPAIR 6 <br /> REPLACEMENT❑ I. <br /> DISTANCE TO NEAREST: Septic Tank _ f 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 0 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation — — <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - --- --- <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing — --- - <br /> IRRIGATION r'13 GRAVEL PACK Depth of Grout Seal — —' <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ Other Information — — <br /> ❑ GEOPHYSICAL SuaceSeal Installe By. — <br /> PUMP INSTALLATION: <br /> Contractor_ /;� <br /> Type of Pumpr�-�-�-R H.Pi I <br /> PUMP REPLACEMENT: 13 State Work Done <br /> PUMP REPAIR: tsState Work Done T— <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 /> Home owner or licensed agent's signature Certifies the following:"1 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 /> Contractors hiring or sub-contracting signature certifies the tollowing:"1 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 wif li for a Grou�Inectionprior outing and a tinct Inspection.Signed X _ Title: // — - Date: <br /> (Draw Plot Plan on 9everbt 51 dei <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I //`' <br /> 11�plcd?i�;n Acccpl�d >3y /u D ir_. .- S� t 9 <br /> iiLA — <br /> Phase II Grout pe: on f Phase III Final Inspec <br /> inspection By Date_ — Inspection By— Date —..- <br /> Fee IS Due: ❑ ANNUALI Y ❑ PEN UNIT IQ PER S'I E ❑ FA�:H ❑ Jan..wy tI neceiveo lay danjary 31 ❑ J..Iy I ­J By J-'y 31 <br /> 77-FS <br /> � <br /> - t3A5E F%PLANATIOty i FSILLING REMITTANCE S AMOUNT DtJE CHECKED <br /> DATE UA'E HEMITTFn AMOUNT <br /> FEF — <br /> LESS <br /> P40RaTioN -- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> c7 rHER <br /> -�- <br /> �,.;;c.,,.� Rocv:pf No Peri it No Issuance Date Mailed Deuve•ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT.'SERVICES 1001 E HAZELTON AVE,P.O.But 2009 STOCKTON.CA 9520 <br />