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I a&"&&1r6kes& Submitted Properly Completed. BeSureToSign TheApplication. <br /> fF!.J I ]k APPLICATION <br /> FOR OFFICE USE: . <br /> 19$11 or Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> A AUG 1 I ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICAfk,�N i0p`GUIN-LOCAL <br /> WATER QUALITY 3"0-(c� <br /> Application is hereby made to J u�lL�eal'i�t��thDistrictto,apermit toconstruct and/or`install the work.herein described.This application is <br /> made in compliance wit San J aquin Cou ty Ordinance No. 1 62 and the r les and regulations of the San Joaquin Local Health District. <br /> 'Exact Site Address_ �1 �� h�` ' � — City/Town <br /> Owner's Name �✓ Phone <br /> Address es��� CityI e „ <br /> Contractor's Name License# usiness Phone 1 <br /> Contractor's Address `�� i���� Emergency Phones. <br /> Is Certificate of Workman's Compensation Insurance on f=ile With SJLHD? Yes s/ No. <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION , PUMP REPAI <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 /> ❑ INDUSTRIAL - - ❑ CABLE TOOL Dia. of Well Excavation i <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> "RYIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout '! <br /> ❑ DISPOSAL ET OTHER OTHER Other Information � <br /> ❑ GEOPHYSICAL 1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Tyy H.P. <br /> pe of Pump - <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: ___Well Diameter:_ _ «_ �Approximate Depth <br /> Describe Material and Procedure <br /> � 1 <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. y <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit \r <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." V <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work tot 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 in tion. <br /> ,//� <br />`E `v'�.C T; -i' _ Date: *- -x <br />�. Signed X _ <br /> ++ (Draw Plot Plan on Rever e)� ` d <br /> 4r� 1 <br /> 7 <br /> l F R D PARTME T USE ONLY <br /> PHASE <br />,.. Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout inspection Phase III Final inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: 13,ANNUALLY ❑ PER UNIT .-❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 '❑ July 1 &Received By July 31 <br /> � REMIT <br /> BASE EXPLANATION BILLING .REMITTANCE $ AMOUNT DUE' CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> i <br /> FEE { <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> j <br /> OTHER <br /> 7 <br /> {i <br /> OTHER <br /> F <br /> Received by Date - Receipt No. Permit No. Issuance Date Mailed Delivered <br /> STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ;ENVIRONMENTAL HEALTN PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 - ' <br />