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.,...arm. .•�1ar+os-w.�r —i=_ j I <br /> Applications-Will Be Processed When uAPPLICATION <br /> FOR•OFFtrE USE: <br /> {For Non-Transferable, Revocable,Suspendable} PUMP&WELL n <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) ' <br /> Application is hereby madetotheSan.JoaquinLocdlinancehNo$1862 and pthe rules and regulations oftheSan Jkahuin Lo in es!described. <br /> d" D strriiThis t. S <br /> made in compliance with San Joaquin Co ty,O y City/Town <br /> Exact Site Address • ` L1 phone <br /> r <br /> Owner's Narrie _ ity ) <br /> Address `�� Lic nse# 'YRusin Phone I <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No r r <br /> is Certificate of Workman's Compensation lnsu nce on File With SJLHD? Yes DESTRUCTION <br /> TYPE OF WORK (CHECK): NEW WELL DE❑ OTHER ITIO UMP INSTALLATION PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br />` DISTANCE TO NEAREST: Septic Tank Other <br /> Cesspool/Seepage Pit <br /> l Sewage Disposal Field Public Domestic Well <br />! Property Line Private Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE Dia. of Well Excavation of <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> ❑ DRILLED Dia. of Well Casing <br /> I ❑ DOMESTIC/PRIVATE �� <br /> VEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC <br /> AVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of.Grout <br /> ❑ CATHODIC PROTECTION ROTARY <br /> 13OTHER Other Information <br /> ❑ DISPOSAL . urface�eal Installed By: <br /> 13 GEOPHYSICAL 'I C <br /> Contractor � � �- i .(/ r <br /> PUMP INSTALLATION: - H-P" <br /> Type of Pump <br /> 11State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> certify that I have prepared this application and that the work will Hbe done <br /> Disinaccordance with Sa7Joaquin ounty <br /> I hereby Yordinances, state laws, and rules and regulations of the San Joagaertif that in the performance of the workfpermitHome owner or licensed agent's signature certifies the following:" Yis issued, 1 sha44 not employ any person in such manner as to become subject to workman's compensation rniaiContractor's hiring or sub-contracting signature certifies the foliowing:"I certify that in the performance of thech this <br /> loy persons subiect to workman's compensation laws of California." <br /> permit is issued, I shall emp <br /> I I wit call for a ut inspe lion Pr or to grouting and a final insQectio v ,E Date- <br /> l, Title: <br /> Signed X, (Draw Plot Plan on Reve a Side) <br /> r FOR DEPARTMENT USE ONLY <br /> Date <br /> PHASE 1 <br /> Application Accepted By <br /> Additional Comments. hose lli final Inspection <br /> Phase 11 Grout inspections Inspection By Date <br /> inspection Bye.' 64- Date <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMIT By July 31. <br /> Fee Is-Due: [I ANNUALLY CHECKED <br /> BILLING REMITTANCE - $ AMOUNT DUE <br /> EXPLANATION DATE REMITTED AMOUNT <br /> "BASE DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Issuance Date Mailed Delivered <br /> t L <br /> Receipt No. Permit No. <br /> I. Received by � D to 1641 E.HAZELTON AVE.,P.O.box 2009 STOCKTON, <br /> eceCA 95201 <br /> TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> APPLICANT—RETURN ALL COPIES <br />