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-� .. _ . <br /> Applications Will Be Process+�3~When'Subm t e roper y <br /> r FOR OFFICE USE: - <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) POMP&WELL h <br /> ENVIRONMENTAL HEALTH PERMIT to " <br /> WATER QUALITY f� <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby madeto the San Joaquin Local Hi3alth Districtfora permitto construct and/or install thework herein described.Thisa pplication is (I}' <br /> made-in.compliance with San Joaquin County Ordinance No. 1852 and the rules and reguilations of the San Joaqui Loca H alts h District. <br /> c� City/Town <br /> Exact Site Address r { (yr" I rliwr�t <br /> Phone <br /> " Owner's Name Gity <br /> Address <br /> 3r Business Phone <br /> Contractor's Name C-�' icense# <br /> Contractor's Address ency Phone <br /> No � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ _ CTNo ❑ l <br /> TYPE OF WORK (CHECK): NEW WELL IJ DEEPEN ❑ RECONDITION❑ DESTRU ; <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 11 PUMP REPAIR❑ <br /> REPLACEMENT❑ Pit.Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other ' <br /> Property.Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> f 59 DOMESTIC/PRIVATE <br /> ❑ 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 /> ❑ <br /> DISPOSAL <br /> 13 OTHER Other Information <br /> Surface Seal installed <br /> ❑ GEOPHYSICAL <br /> Contractor M,k/ - <br /> � PUMP INSTALLATION: / � H.P. lam, <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ® State Work Done d < <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> = Describe Material and Procedure <br /> l hereby"ce"rtify"that 1 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 /> 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 /> ' Coiiiractor's hiring or sub-contracting signature certifies the fallowing'"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 /> I will call for a Grout Inspection r to gr I and a al inspection. w `t <br /> Signed X <br /> 6� (At Ille: 1�40 0p-/ Date: fF <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY �Q <br /> PHASE I Date `� <br /> Application Accepted By <br /> Additional Comments: <br /> e - a1 Ins � `Z <br /> s �-� <br /> Phase IAI Groui Inspection pection <br /> Inspection By <br /> Date Inspection By Date <br /> L4 " <br /> e:d By J <br /> Fee ISDUe: ❑ ANNUALLY .❑ PER UNIT K� PER SITE. EACH January 1 &Received By January 31 July 1�R.ReceivREMIT <br /> ti s BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT" <br /> f FEE e d /L <br /> LESS s <br /> PRORATION. <br /> PLUS <br /> PENALTY �'Ol <br /> !r <br /> OTHER <br /> OTHER S 19! twirl f <br /> r <br /> s --7 qC 3 5 s C� ' <br /> l Permit No. Issuance Date Mailed Delivered <br /> Received by., Date Receipt No. <br /> ' —_ - <br /> APPLICANT-RETURN ALL�COPIES_TD} ENVIRONMENTAL HEALTH`PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 4520 <br />