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Applications Wf11 Be Processed When Submitted ro <br /> APPLICATION <br /> FOR OFFICE USE: I (For Non-Transferable, Revocable,Suspendable) 1 pump&WELL <br /> ENVIRONMENTAL HEALTH PERMIT L <br /> WATER QUALITY rk herein <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin LocaLHealthNos1862 and rutles and egulattiions oftthe San Joaquin Local Healltth District,This .application Is <br /> made in compliance wi San Joaquin County OrdinanceCity/Town ,�c� <br /> Exact Site Address Phone <br /> oe <br /> Owner's Name �'p City <br /> Address License#�— Business Phone <br /> 4j' , �. <br /> Contractor's Nam Emergency Phone <br /> Contractor's Address/r - ` ifs i� No <br /> Is Certificate of Workman's Compensation Insur . ce on File With SJ LH D? Yes <br /> ESTRUCTIOND <br /> TYPE OF WORK (CHECK): NEW WELL❑ MENT ❑DEEPEN ❑ OTHERO❑ 1T10 ©P INSTALLAT ON PUMP REPAIR❑ } <br /> WELL CHLORINATION ❑ WELL ABANDON <br /> REPLACEMENT❑ .{ Sewer Lines — Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank ! Cesspool/See <br /> f/ page Pit Other i <br /> Sewage Disposal Feld��4 - public Domestic Well <br /> Property LineX �r�-Private Domestic Well — <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> 13DOMESTIClPUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout <br />+ <br /> 13 CATHODIC PROTECTION ❑ ROTARY <br /> 13 OTHER Other Information <br /> 11 DISPOSAL Surface Seal Installed By'. <br /> ❑ GEOPHYSICAL. <br /> PUMP INSTALLATION: Contractor P <br /> Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> � a PUMP REPAIR: Approximate Depth , <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> t the-work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this application and tha <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 ferias togbecome subject to workmant in the 's co oceof the work f laws of Califoor which this rnia." <br /> is issued, I shalt not employ any person in such mann <br /> Contractor's hiring or sub-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 /> kl will call for a Grout In ection prior to grouting and a final inspection. Dater <br /> T til `�' <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> r <br /> FOR DEPARTMENT� USE ONLY <br /> PHASEI V <br /> lVLp� Date <br /> Application Accepted By <br /> Additional Comments: P s III Fi I Inspection <br /> Phase 11 Grout Inspection � Date <br /> Inspection By— - � <br /> Date inspection 8y <br /> � ❑ January 1 Received 8y January 31 ❑ July 1 &Received 8y JuVy 31 <br /> Fee Is Due: ❑ ANNUALLY <br /> El PER UNIT ❑ PER SITE 'El REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE. DATE REMITTED AMOUNT <br /> C] <br /> FEE <br /> LESS <br /> r PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> k <br /> OTHER <br /> Receipt No. Permit <br /> Issuan Date -Mailed Delivered <br /> Received by Date � 40. 1601 E.HAZELTON AVE..P.D.Box 2009 STOCK70N,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />