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......7.. ..._ �r <br /> I <br /> iMIA l e oc a nSubmitted <br /> Fp APPLICATION <br /> FEB 2 4 1982 (For Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> VIRONMENTAL HEALTH PERMIT <br /> ,�CAQUIN LOG ► . <br /> ( T �1" DISTRICT WATER QUALITY <br /> COMPLETE IN hereby <br /> CA <br /> Application is hereby made tote an Joaquin Local Health District for a permitto construct and/or install the work herein described,T is application <br /> made in compliance with San Joaqui unty Ordinance 1862 and he rules and regulations of the an oaqui Local Health District <br /> Exact Site Address City/Tow r•-, � <br /> Phone 5 <br /> Owner's Name <br /> City <br /> Address <br /> �106License# v Business Phone <br /> *ontractor's Name Phone <br /> �., <br /> Contractor's Address -��Y a 7 Emergency <br /> s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No G} <br /> { <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT 13 OTHER 11 PUMP INSTALLATIONa� PUMP REPAIR❑ �f <br /> REPLACEMENT❑ I <br /> s Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Line <br /> Ce <br /> Sewage Disposal Field sspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> I Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ CABLE TOOL , <br /> ®r 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 /> t <br /> i I�PUMP INSTALLATION: JContractor <br /> o End1q0b 4t 5 !NG <br /> Type of Pump 1) 1AMs'rt f, S isxgg&I H.P. — <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: _-❑ State Work Done - - w <br /> r Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 /> r" Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> k 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 willcallcall for a Grout Ins ction pr' to grouting and a final inspection. <br /> F XSigned X l M► _ _ __ - Title Date <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q Date ` <br /> Application Accepted By a �S> <br /> I <br /> Additional Comments: <br /> Phase II Grout Inspection P� a Iii a nspVVf-" <br /> r Inspection By Date <br /> Inspection lay Date ^- <br /> Fee l5 Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> BASE EXPLANATION BILLING REMITTANCE I AMOUNT LIVE CHECKED - w <br /> BATE DATE REMITTED AMOUNT <br /> Y FEE <br /> E <br /> LESS # <br /> r PRORATION <br /> PLUS <br /> PENALTY <br /> t <br /> OTHER y <br /> OTHER ; <br /> yVl a a [ 1 oLS 1 s 11 � �r <br /> - Permit No. Issuance Date Maned Delivered <br /> Received by Date Receipt No. —fr <br /> APPLICANT—RETURN ALL COPIES T:O:. ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.HAZELTON AVE,,P.O.Box 2009 - STOGKTON,CA 9520 , <br />