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4p — — W-. diJ <br /> pications Will Be Process en Submitted Properly Completed. Be Sure To Sign The.Application. <br /> FOR OFFICE US 1! n t APPLICATION <br /> - JUL 191982 (For_Non-Transferable, Revocable, Suspendable) y <br /> -A'~ PUMP&WELL <br /> A � ��� �IVIRONMENTAL HEALTH PERMIT <br /> QUALITY(COMPLETE IN TRIPL /�I��- <br /> ICT6� DISTRICT WATER Q <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permitto construct and/or install theworkherein described.Thisappllcationis <br /> made in compliance,with San Joaquin County Ordinance No. 18162 and the rules and regulations of the San Joaquin Local Health District. I <br /> Exact Site AddressCity/Town <br /> Owner'sN,�me " �Z Phone_ <br /> Address 7 - City <br /> Contractor's Name � _+r ?►A=i ��'1 License# Business Phone <br /> Contractor's Address Emergency Phone ) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank03 Sewer Lines _ C) Pit Privy 1 <br /> _.. Sewage Disposal Field Cesspool/Seepage Pit Other <br /> z Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE T TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL ---Dia. of Well Excavation <br /> -- <br /> .11 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 2 <br /> tK,pOMESTIC/PUBLIC....- - [TDRIVEN Gauge of Casing-:--i- <br /> ❑ IRRIGATION RAVEL_ PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION JiLZOTARY Type of Grout �SAC 9� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> El GEOPHYSICAL' <br /> Su ac eat Installed By: z - <br /> PUMP INSTALLATION: { Contractor .. <br /> Type of Pump r' H.P. <br /> PUMP REPLACEMENT: CO—state Work Done <br /> PUMP REPAIR: ❑ State Work Done <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. l <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, 1 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 subject to workman's compensation laws of California." <br /> I will call for a Grout Ins tionpriorto grouting and a final inspection. <br /> /� . <br /> Signed X Title: �t k-S T �/Uf S- _ Dale: 7 <br /> ( raw Plot Plan on Reverse Side) �� - <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> E Application Accepted By r`► - � � Arc's Date ` 1�—FD-_ <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha 111 Final inspection <br /> Inspection By Date Inspection By Date 2— <br /> Fee <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> :i REMIT -I <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT t <br /> { <br /> FEE ' <br /> LESS j <br /> P90RATION - <br /> i <br /> PLUS 'pe <br /> PENALTY <br /> i OTHER <br /> - 1 <br /> GT4I�E/R� <br /> t Received by ate Receipt No. Permit No. I Issua ce Date Mailed Delivered <br /> l <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.P.Boa 2409 STOCKTON,CA 95201 <br />