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ApplaL(�15 Will BeProcessed Where witted ProperlyCompletea. tiesure 10Olgn tFIV <br /> FOR OFFICE USE: AU G 13 1979 APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> SAN HEALTH DISJORQUIN ' NMENTAL HEALTH PERMIT <br /> ,; <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San oapl�n County Ordinance Nom. 1�2 a�e�uless annd egulations of the S S�qui Lo a Health District. <br /> Exact Site Address !"E + G(, sty/Town <br /> C.LJ 9�'TA �13 ✓Jf� 1;�`r�1�, �S7,01= W11 <br /> 1 s'7"` Phone <br /> Owner's NaIT>� <br /> Address f� City <br /> Contractor's Name 1' U� 7 License# ��7� Buss Phone <br /> Contractor's Address A 1, 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 <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 pia. 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 /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done ` <br /> PUMP REPAIR: ;R'State Work Don <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 0 <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. <br /> Homeowner or licensed agent's signature certifies the following:1 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 forwhich this <br /> permit is d, shall employ persons subject to workman's compensation laws of California." <br /> I it t Inspection prior to grouting and a sinal ins c ion. <br /> Signed X Tit Date: <br /> (Draw Plot Plan n Reverse Side) <br /> FO DEPART ENT USE ONLY <br /> PHASE k /3 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase Ii Grout Inspection .Pha III Final Inspection <br /> Inspection By Date Inspection By <br /> t,a <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 1 ❑ July 1 & eceived July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED �f AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuafide Date Mailed Delivered <br /> RVlCE5 1601 E.HA2ELTON AVE.,?.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SE <br />