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t Applications Will Be Processed When Submitted Properly Complete <br /> `dtbler� '(t ,Si a Application. - - <br /> FOR OFFICE USE 3 APPLICA I � � 1 <br /> tJJ <br /> (For Non-Transferable, R v"' b " gapendable) <br /> ENVIRONMENTAL 1 i�1 TH *J '19 <br /> $1 PUMP&WELL <br /> ��-`' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY tt t <br /> Application is hereby made to the San Joaquin Local Health District fora permit to constrf�u arid'/. t t e rkk1herein described. This application is <br /> k made in compliance wi n o in �tyQrcfiLl a 862 and the rules an�4iky ipt�o Cyt <br /> r� `�iof`the Sanquin Lp He�tth Di ict. <br /> I <br /> Exact Site Address City/Town / /T�� �'" <br /> Owner's Na �G V(5W SrJru <br /> Phone, <br /> Address <br /> Address A-1 City L <br /> f Contractor's Name .+� ) v/Vl License# .� Business Phone <br /> Contractor's Address �f}srJ� Emergency Phone Qom/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No r <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ V 1 <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 /> ❑ili�IDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 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 /> I ❑ GEOPHYSICAL <br /> � Surface Sea! Installed By: <br /> PUMP INSTALLATION: Contractor <br /> r <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 4 PUMP REPAIR: R-State Work Done <br /> A DESTRUCTION OF WELL: Well Diameter <br /> 4Approximate Depth <br /> Describe Material and Procedure <br /> ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> k ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br />{i 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 mannor as to become subject to workman's compensation laws of California." <br /> fr Contractor' ringWI (Draw <br /> signature certifies the following:"I certify that in the performance of the work for which this <br /> l p + sued, s subject to workman's compens ' laws of California." <br /> 1 w t gro ting and a final inspectio . <br /> Signed X Date: f <br /> _ .,.�. Title:(Draw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY , <br /> 4 PHASE I <br /> Application Accepted By Date "n—gi <br /> Additional Comments: <br /> Phase it Grout Inspection s Fi I spection / <br /> Inspection By DateInspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive`d By January 31 El July 1 &Received By July 31 <br />` BASE JEXPLANATION - BILLfNG REMITTANCE $ REMIT <br /> DATE DATE REMITTED <br /> AMOUNT DUE CHECKED � <br /> E.' AMOUNT r <br /> HLESS <br /> v p <br /> , <br /> 4 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received 1,y Date r `Receipt No. Permit No.. - .. is ante ate' Mailed Delivered -- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E.HAZELTpN AVE.,P.O.BOK 2009 STOCKTON,CA 95201 <br />