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ApplicationsWill BeProcessedWhenSubmitted Properly Completed. EFe-bureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION; <br /> (For Non-Transferable, Revocable Suspeit�a ) <br /> TFi �"! / PUMP&WELD. <br /> ENVIRONMEN7w k-li�'AI.TH PERMI <br /> (COMPLETE IN TRIPLICATE) f*ATE' QUALITY 1981 <br /> Application is hereby made to the San Joaquin Local Health District f4 ermit V tand/orinstta�lltheworkhereindescribed.Thisapplicationis <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the ru es and regutlatigrt';lgffti�e San Jaquin Local Health District. <br /> Exact Site Address . / ✓ " tw`"` _6tyy�c�wn t t <br /> 4 - <br /> Owner's Name � �='-.�- Phone�. <br /> Address -p City .f .I <br /> Contractor's Name t1 License# c� Business Phone_ <br /> Contractor's Address ___ate�/a 2 Emergency Phoneit T <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIRL� <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 /> V11NDUSTRIAL C3 CABLE TOOL Dia. 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 94f t.�/ 3W �.r. �1iF �4Ao0e.,, <br /> PUMP REPAIR: 13 State Work Done -- V '°r" <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <br /> 1 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. CIQ <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance ofthe 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 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 Inspection prior to grouting and a final inspection. <br /> Signed X ha ,6"Lo Title: Date: - d <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ! <br /> PHASE t \WUL / �l <br /> Application Accepted By Date Al l <br /> Additional Comments: <br /> P e l Grout Inspection P se I Find Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: © ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 [] July 1 &Received By July 31 , <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> [� AMOUNT <br /> ow <br /> FEE 1`� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No I Issua ce I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HA2:ELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />