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Jy <br /> Applications Will Be Processed When Submitted Properly Completea. <br /> APPLICATIONi Q <br /> FOR OFFICE USE: f <br /> G_. (For Non-Transferable, Revocable, Suspendable) PUMP&WELL r" <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY � <br /> (COMPLETE IN TRIPLICATE) <br /> tion is madetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/arinskalltheworkhereindescribed.Thisapplicationis <br /> A Ilca Y Health District. <br /> pP an Joaquin Local H <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the S q i5r y <br /> 11 PL© City/Town <br /> Exact Site Address <br /> / <br /> Owner's Name Phone -�yf�q ^r�G+9 <br /> City <br /> Address <br /> IN N CtiS RDS I License# ® f Business Phone <br /> j Contractor's Name <br /> w..• � E B Emergency Phone <br /> Contractors Addres No <br /> Is Certificat,of Workman's Compensation Insurance on File With SJLHD? Yes <br /> fTYPE OF WORK (CHECK): NEW WELL'K "DEEPEN ❑ RECONDITION DESTRUCTION❑_ 1. <br /> I WELL CHLORINATION WELL ABANIlDONMENT'❑ OTHER ❑ PUMP INSTALLATION ❑ u PUMP REPAIR❑ <br /> REPLACEMENT❑ Ph i a.-O P), <br /> DISTANCE TO NEAREST: Septic Tank it Sewer Lines 40 Pit Privy <br /> . Cesspool/Seepage Pit Other <br /> Sewage Disposal vFiielld 2 <br /> Property Line"tir Private Domestic Well r Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 74 <br /> E3DOMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing �� o <br /> ❑ IRRIGATION S GRAVEL PACK a Depth of Grout Seal c-Ti5ing V_7- <br /> (� <br /> ❑ CATHODIC PROTECTION <br /> * ® ROTARY Type of Grout <br /> ` <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: # Contractor _ z <br /> Type of Pump H.P. 1%. <br /> PUMP REPLACEMENT: 11State Work Done <br /> PUMP REPAIR: ❑ State Work Done ,` O <br /> .:,y Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: ' <br /> I Describe Material and Procedure i` <br /> f 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 /> i <br /> Homeowner 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 shah 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 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 pribr`to grouting and a final inspect'q / <br /> Date: <br /> Signed X Title: <br /> '(Draw Plot Plan on Reverse S de) <br /> I I FOR EPART ENT USE ONLY <br /> PHASE I , Date <br /> i Application Accepted By r <br /> Additional Comments: <br /> eCtion t P se 111 Fi at Inspection <br /> Phase 11 Grout Insp —A? <br /> k <br /> Inspection By Date M 7 Inspection By Date <br /> } <br /> .I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER . <br /> < fi � �79_11� c� 1S <br /> is 7� <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by ( 1601 E.HAZELTON AVE.,P.O:avx 2009 STOCK70N0241 <br /> AL HEALTH PERMIT/SE <br /> 'APPLICANT-RETURN ALL COPIES TO: ENVIRONMENT <br /> RVICES <br />