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,.�..�... � Applications WOII=Be Processed When Submitted Properly Completed. i3e <br /> FQR OFFICE USE: . <br /> APPLICATION <br /> (For Non-Transferable, Revocable,5uspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY *f <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescribed.Thisapplication,•is i <br /> made in comp is ce ith San Joaquin Cc my Ordinance No.1862 and thg-rules and regulati o f the San Joaquin Local Health District. G <br /> n f PL f1? cab. — y/ b n � �'f l 15f!' Q/1,— <br /> Exact Site o�S oc 7"f 2L <br /> Fr�cr�Kf - Phone <br /> Owner's Name City G <br /> Address �. �7 - <br /> Contractor's Name lC��-� ��' License# Z9tJ Business Phone <br /> �� 0 0� _ Emergency Phone <br /> Contractor's Address f No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> ❑ DESTRUGTION❑ <br /> TYPE OF WORK (CHO=CK): NEW WELL DEEPEN El RECONDITION <br /> , <br /> ❑ WELL ABANDONMENT ❑ OTHER ❑ PSUMP INSTALLATION❑ PUMP REPAIR❑ <br /> I N 3 <br /> HLORINAT O j <br /> WELL C � 1 <br /> I REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> c. DISTANCE TO NEAREST: Septic Tank ___�1� Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br />! Property Line --Private domestic Well <br /> Public Domestic Well " �i <br /> INTENDED USE TYPE OF,.WELL r� <br /> ❑ <br /> ❑ INDUSTRIAL CABLE;TOOL Dia. of Well Excavation <br /> I ❑ DRILLED� - Dia. of Well Casing „y <br /> DOMESTIC/PRIVATE Gauge of Casing <br /> 11 DRdlEl i <br /> ❑ DOMESTIC/PUBLIC. r <br /> 11 IRRIGATION 0�{ GRAVELPACK Depth of Grout Seal <br /> ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION <br /> ❑ OTHER _ Other Information <br /> 11 <br /> DISPOSAL <br /> ❑ GEOPHYSICAL Surface Seal Installed 8y: - <br /> f _% —,,_ . <br /> PUMP INSTALLATION: Contractor_ H.P.- <br /> Type <br /> pType of Pump. <br /> PUMP REPLACEMENT: ❑ State Work Done +t <br /> t ❑ State Work Done <br /> r PUMP REPAIR: <br /> f Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL• r � . <br /> -Describe-Material and Procedure": <br /> 1 hereby certify that l have prepared this application°and.that the work will be done in accordance with San Joaquin County <br /> t ordinances, state laws, and rules and regulations of the,San Joaquin Local Health District. <br /> r� <br /> Home owner or licensetl agent's signature certifies the following:"I certify that in the performance of the work f r which this permit <br /> subject to workman's compensation l <br /> is issued, I shall not efiploy any person in such manner-4s to become laws of California." <br /> I Contractor's hiring ars b-contracting signature certifies the following:"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 /> will call for a Grout 4'spection prior to grouting and a final inspect' n. <br /> 27 <br /> Date: <br /> Signed X <br /> (D aw Plot Plan on Reverse Side) <br /> { F RDE RTMENT SE ONLY �y <br /> PHASE I Date < <br /> Application Accepted By <br /> Additional Comments: h 11 inal Inspection <br /> jz)a,0{L Phase 11 ro Inspection <br /> Inspection By <br /> Date Inspection By Date <br /> r <br /> f PER UNIT C❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANN LY ❑ REMIT ! <br /> 1 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS e^ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER [J ' <br /> ` - Permit No. .Issuance Date Mailed, DeRveretl . <br /> Received by Date Receipt No. w <br /> ..APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES -r <br /> ISM E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br /> l. <br />