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Applications Will Be Processed When Submitted Properly Completed. Be Sure ���gn The Application. ~ <br /> FOR OFFICE USE: APPLICATION SEp 24 1981 <br /> (For Non-Transferable,Revocable;Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN Jr,-1Ar1,'U1N LOCAL <br /> WATER QUALITY HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) �3, . ,y . _ : . �, „ <br /> Application is hereby madetotheSan Joaquin Local Health Districtforapermittoconstruct and/or.installthe'work herein descri bed.This application is <br /> made in compliance with San Joaquin.County Ordinance,No..1 62 and the rules and regulations-of the San Joaquin Local Health District. <br /> Exact Site Address � � � �/ �`.1� City/Town <br /> Owner's Nam ; / /FxL�i ' �ti Phone <br /> �7�/)/� <br /> Address " f. �L` .. CIt <br /> Contractor's Name "s �f License# Business Phone 1 <br /> Contractor's Address MOW t111ZT - t s Emergency PFi9ne ti <br /> Is Certificate of Workman's Co_mpensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELE❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑- PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ Ij <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 /> nb[01D <br /> ENDED USE I„ TYPE OF WELL <br /> STRIAL .ri ❑ CABLE TOOL -- --- �,_..D.ia.of.Well Excavation <br /> ESTIC/PRIVATE I ❑ DRILLED Diavof Well Casing <br /> ESTIC/PUBLIC ❑ DRIVEN �t�G'auge of Casing <br /> IGATION s, �0_GRAVELPACK.-�. --Depth.of Grout Seal <br /> THODIC PROTECTION ❑ ROTARY Type of GroutPOSAL f Ill ❑ OTHER ...T�J -_- -- Other Information <br /> iOPHYSICAL ij �µ Surface Seal Installed By: <br /> PUMP INSTALLATION: ;j � Contrac ori <br /> T. <br /> ID <br /> Type of Purrip<.. r -1 _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: I tate Work Done <br /> DESTRUCTION OF WELL: ,. - i } Well.Diameter TM_ j Approximate Depth i. <br /> Describe'M'ate5riai•and Procedure <br /> I hereby certify that I have,prepared jfhis applicThibn and that the�work Will be done in`accordance with San Joaquin County <br /> ordinances!state laws, and.ru les and regulatCons of the San Joagltin 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 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 sub"ct to wo man's compensation laws of California." <br /> ca for a Grout Inspects rior to outing a final inspec itit on: <br /> I �- <br /> Signed X # - Title-r Date: <br /> ► (Draw Plof Plan on Reverse Side) <br /> r' <br /> p FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted ByN Date c --, <br /> Additional Comments: 0. r <br /> .Phase 11,Grout Inspection Phase 111 Final Inspeetion <br /> Inspection By Date Inspection By Date <br /> ;a <br /> Fee Is Due: ❑ ANNUALLY [],PER UNIT ❑ PER SITE` ❑ EACH` ❑ January-1 &Received By January 31 El July 1 &Received By Juiy 31 <br /> REMIT <br /> BILLING _REMITTANCE $ <br /> -- <br /> BASE EXPLANATION - AMOUNT DUE CHECKED ' <br /> i DATE , DATE REMITTED AMOUNT ^ <br /> LJI/ li e - <br /> FEE ' <br /> LESS ;I <br /> PRORATION <br /> PLUS <br /> PENALTY 4 - <br /> OTHER ,i �. <br /> :..OTHER <br /> i <br /> Received hy',, Date II Receipt No. Permit No. Is ance ate .Mailed . Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />