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' .0 Applications Will Be Processed When Submitted Properly et (Oe ure a gn e (cation. <br /> FOR oFFicE USE: APPLICATI i <br /> (For.Non-Transferable, Revocab spendal k <br /> -� - ENVIRONMENTAL HEALTH PE <br /> 90' 1981 PUMP&WELL <br /> (COMPLETE IN TRIPLICATE)` ' WATER QUALITY SAKI iCiA °UIN LOCAL <br /> Application is hereby madetothe San Joaquin Local Health Districtforapermit toconstruct"/ALilT?11ID�&PR(h._pTeindescribed.Thisapplicatioriis <br /> made in compliance with San Joaquin County Ordinance No. 1862 qDd the rules and regulations of the SLocal Health District, <br /> Exact Site Address ® 0 l City/Town ,� r <br /> Owner's Name Phone <br /> Address /600 /ccam� �Z. =jZ� City ' <br /> Contractor &'s Name License#/6-2,.373 Business Phone��-�� <br /> i Contractor's.Address «Q t ..__ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on "File With SJLHD? Yes No <br /> i TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> s <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR T-�s <br /> REPLACEMENT❑ <br /> F DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Ir <br /> r <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 9` <br /> Property Line Private Domestic Well .. .Public Domestic Well <br /> INTENDED USE £ "--�-TYPE OF WELL <br /> ❑-INDUSTRIAL ❑ CASLE_T.00L = _-- Dia...of..Well_Excavation, { <br /> l ❑ 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 /> ❑ GEOPHYSICALSurface Seal Installed By: `� <br /> SUMP INSTALLATION; Contractor O .� <br /> Type of Pump H,P. <br /> d <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0-State Work Dane <br /> OF <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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. <br /> Home owner or licensed agent's signature certifies the following:r'I 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 folio-Wing 'I certify that in the performance of the work forwhich this <br /> permit is issued , I shall employ persons subject to workman's compensation laws of California." , <br /> I Za?llor a Grout I ction prior to grouting and a final inspection. <br /> u <br /> "'?_-Signed X itle: Date: <br /> " - (Draw Plot Plan on ReversS Side) - _- <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By � + �`' '�- Date <br /> Additional Comments: <br /> # Phase II Grout Inspection ha _III_Final_Inspection p r � ' <br /> Inspection B:y on Date Inspection By� pate <br /> Fee IS Dui?: ❑"ANWUALLV ❑ PER`UNIT- ❑-:PER SITE '❑ EACH- '_"❑"Janusry�l-&-Received"By January 31' ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING.. -..REMITTANCE $ AMOUNTDUE CHECKED <br /> DATE �`DAT.E REMITTED <br /> AMOUNT _ <br /> FEE -A <br /> i <br /> LESS 6 <br /> PRORATION 1 <br /> PLUS * <br /> PENALTY 3 '� <br /> OTHER = Xf <br /> OTHER k a �^✓ x*r <br /> E <br /> 4 Received byDate Receipt No. Permit No .�¢t Issuance Date " Mailed ,Deli4ered `} <br />►. <br /> `'� APPLICANT—RETURNl ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES <br /> 1601 E.HA2ELTON AVE-,P.O.Boy 2009 STOCKTON,CA95201 <br />