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Applications Will Be Processed When Submitted Properly Completed. Be Sure <br /> F I E USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.This application is <br /> made in compliance with Joaquin unty rdinance o. 1862 and the rules and o� <br /> regulations of the San) uin Local Health District. <br /> City/Yawn <br /> e <br /> • g <br /> Exact Site Addr C nhr �S � <br /> 4 � ! Phone <br /> Owner's Name <br /> Address j L City <br /> Contractor's Name � _ <br /> q f License# f Business Phone _5 7 <br /> Contractor's Address Emergency Phone <br /> ~ Is Ce Mio-4te ofWorkman's Compensation insurance on File With SJLHD? Yes NO �} <br /> TYPE OF WORK�(CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ __f) <br /> f WELL CHLORINATIQN_❑ ..;j.W.ELL�ABANDONMENT 0 _ OTHER ❑ PUMP INSTAL-L-ATION�0 PUMP REPAIR❑ <br /> REPLACEMENT❑ 4. <br /> k DISTANCE TO NEAREST:-""ie_0 c Tank Sewer Lines <br /> Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line d Q Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL K.. ❑ CABLE TOOL Dia:of Well Excavation <br /> IM ❑ DRILLED <br /> DOMESTIC/PRIVATE - Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal } <br /> 0-CATHODIC PROTECTION. ❑ ROTARY Type of Grout - <br /> ❑ D140SAL �� ❑ OTHER Other Information F \ <br /> GEOPHYSICAL <br /> Surface a Ins�Iteo, y: t + �' <br /> i PUMP INSTALLATION: Contractor <br /> $ r Type of Pump H.P. ` <br /> PUMP REPLACEMENT: e ❑ State Work Done, ` <br /> PUMP REPAIR: ❑ State Work Done <br /> f DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> [! Describe Material and Procedure <br /> k I hereby certify t(aat I have prepared this application and that the work will be done in accordance witWSan 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:"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 following:"I certify that in the performance of the work for which this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." <br /> I ill call for a Gro Inspection p"r to grouting and a final Inspec ion.^ <br /> X <br /> Title: Date: <br /> Signed <br /> =t (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ✓' -` ! llo gC7 <br /> �.-- Q.3'`:. Date <br /> Application Accepted 8y'`- <br /> Additional Comments; <br /> Phase 11 Grout Inspection Inpecton hase III Final Inspection <br /> IF <br /> �`-t` U� siBy Date <br /> Inspection By Date_—� _ � a <br /> �- Fee IS Due: 11ANNUALLY ❑ PERUNIT .❑ PER SITE - ElEACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> -EXPLANATION —BILLING REMITTANCE - $ AMOUNT DUE CHECKED <br /> BASE-%. DATE DATE REMITTED AMOUNT <br /> 0 <br /> FEE ° <br /> LESS <br /> PRORATION 3 - <br /> . <br /> PLUS - <br /> PENALTY 'may <br /> OTHER 1 V <br /> k \ <br /> OTHER <br /> 3o46 <br /> F <br /> ate Receipt No. � Permit No Issuance Date Mailetl Delivered <br /> Received by ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box2409 STOCKTON,-GA 95201 <br />