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.r Applications Will Be Processed When Submitted Properly Completed. Be5ureTosign inewppucaiwn. <br /> f _OF"°�cE use: ( APPLICATION-! <br /> (For Non-Transferable, I ae, tsd PUMP&WECLL V <br /> ' ENVIRONiAL`TH PER <br /> *R' QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District erI o t ct and!,orrin�s all the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance Na 186 and the rules andat1�U r't' ie San Joaquin Local Health District. <br /> Site Address (0" �'l�cl�own LOQ <br /> Exact S� J� € <br /> A. N GAALEL�L_— L Phone <br /> Owner's Name a -. <br /> AddressHARNE8 <br /> Gity-1.C�p /� Q <br /> Contractor's Name 3�License# �I� Business Phone J J�q' � <br /> j Emergency Phone <br /> Contractor's Address •�• T 3 <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File h SJLHD? Yes ( _ <br /> 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN RECONDITION❑ DESTRUCTION❑ T <br /> AIR <br /> WELL CHLORINATION E] WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11PUMP REP <br /> REPLACEMENT 01 <br /> DISTANCE TO NEAREST: Septic Tan k=r <br /> 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 /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> l 11 DOMESTIC/PRIVATE i❑ DRILLED <br /> 'bio" 4Iof'W 'Casirig' <br /> j:IR:RIGATION <br /> DOMESTIC/PUB ❑ DRIVEN Gauge of Casing <br /> -iNGIFLl�' � ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION <br /> ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> Surface Seal installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor 3 <br /> i <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> fir- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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:"i certify that in the performance of the work for which this permit <br /> ompensation laws of California." <br /> is issued, I shall not employ any person in such mannbr asto become subject to workman's c <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 i s all employ persons subject to wokman's compensation laws of California." <br /> I will c I ut spe ctionrprior to grouting and'a final inspection. "gO <br /> I r. Title: Date: <br /> Signed X <br /> (Draw Plot Plan.on Re rse Side) <br /> 3 F . DEPARTMENT USE ONLY <br /> ` PHASE I i _ Dat <br /> Application Accepted-By <br /> Additional Comments: ..- <br /> Pha II rout inspection Phas 111 Fina inspection <br /> Inspection By <br /> Date � inspection By Date <br /> L <br /> r Fee is Due-..1:1 ANNUALLY ❑;.QER UNITti ❑,=PER SITE El EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> 5 ]' i ..'' '� '" �' "� -,=3i. B}LLING REMITTANCE $ ' AMOUNT DUE CHECKED <br /> '- B.45E ,rEXPLANATION DATE DATE REMITTED AMOUNT <br /> 5 w t <br /> FEE -- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> t l <br /> i OTHER <br /> Received by <br /> - Date Receipt o. Permit No. Issuance Date Mailed pelivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiTISERV10ES - 1601 E:HAZELTON AVE.,P.O.Box 2449 STOCKTON,CA 45241 <br />