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d Properly <br /> Applications Will Be Processed When Sub�mPPeLPCAT�ONp <br /> EOR �,'' E:fi3E: (for Non-Transferable, Revocable,Suspendable) pUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT + <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the5an Joaquin Local Health Dost 862 a dP he rules and regulations oftthe San J workhe herein <br /> uinl LocalcHealth Distrribed.This ict. Is <br /> made in compliance with San.Joaquin County Ordinance N City/Town � <br /> 100 �t7 C o�R sf <br /> Exact Site Address Phone f3Sa'� _ <br /> ' C� <br /> Owner's Name City ��� ► a <br /> Address License# Business Phone_ �6 � ob <br /> Contractor's Name � Emergency Phone �a�I� � � f , <br /> Contractor's Address <br /> Is Certificate of Workman's Compensation Insurance on File SJR CONDITION❑ DESTRUCTION❑ (y, <br /> I WORK CHECK): NEW WELL DEEPEN INSTALLATION❑ PUMP REPAIR❑ —z3��y� <br /> TYPE OF t <br /> WELL CH ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP �� _� 4 <br /> REPLACEMENT 11 ,� Sewer Lines t'R1A�� Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank _ y Other <br /> Cesspool/Seepage Pit <br /> Sewage Disposal Field� � Public Domestic Well <br /> Property Line Private Domestic Well t <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing <br /> DOMESTIC/PRIVATE 13 DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ` Other Information <br /> ❑ DISPOSAL OTHER <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor P <br /> Type of Pump t <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Dori; w <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter d <br /> { v Describe Material and Procedure <br /> t s <br /> repared this application and that the work will be done in accordance with San Joaquin County C <br /> I hereby certify that I have p <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. C <br /> Home owner or licensed agent's signature certifies the 1o1lowing:"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-co signature certifies the following:"I certify that in the per <br /> of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," T y <br /> 1 will call r a GroA Inspection prior to grouting and a final Inspection, T. pate: <br /> Title: <br /> Signed X r <br /> S (Draw Plot Plan on Reverse Side) <br /> i F DEPARTMENT USE ONLY <br /> i <br /> IiPHASE I Date <br /> Application Accepted By <br /> atit 0 <br /> Additional Comments: Phase III nal Inspection <br /> j Ph e 1 Grout Inspection G� Date <br /> Date � ,-?,- inspection By <br /> I. inspection By a. <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ REMIT ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH - CHECKED <br /> BILLING REMITTANCE $ AMOUNT DUE <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> l FEE ' <br /> i LESS <br /> PRORATION ' <br /> PLUS <br /> PENALTY - - <br /> OTHER - } <br /> OTHER11 -7[ 3 � <br /> �� E ` Mailed Delivered <br /> *, Permit No. Issuance Date <br /> Date Receipt No- <br /> � Received by � _ 1801 E.HAZELTDN AVE.,P.4.Box 2009 STOCK74N,CA 9520 <br /> -APPLICANT—RETURN ALL COPIES T4: -ENVIRONMENTAL HEALTH PERMITJSEAY4CES _ <br />