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- Applications Will Be Processed When Submittedroper <br /> FOR OFFICE USE: '�•.� APPLICAT _ <br /> (For Non-Transferable, Revocable, SuWa4e) 1979 PUMP&WELL <br /> ENVIRONMENTAL HEA H PERMIT <br /> WATER QUALITt" JO QUINL(7CAL <br /> (COMPLETE IN TRIPLICATE) HEALTj � TTfll?Wtlt <br /> Application is hereby made to the San Joaquin LoT herein described.This application is <br /> cal Health Districtfora o toSl <br /> ty Ordinance No. 1862 and the rules and regulations <br /> of the City/Town <br /> Joaquin Local Health District, <br /> made in compliance with San Joaquin Coun <br /> ' D <br /> Exact Site Address <br /> Phone <br /> Owner's Name City 16 <br /> AddressLicense <br /> # /�»y��_._�73 Business Phone <br /> l Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> is Certificate of Workman's Compensation I surance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑DONDEEPEN <br /> ❑❑ O E O❑ ITIO N❑P INSTALLA ONO ❑❑ PUMP REPAIR <br /> L� + �; <br /> WELL CHLORINATION [IWELL ABA <br /> REPLACEMENT❑ <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <br /> I Public Domestic Well <br /> Property Line Private Domestic Well - -Y <br /> INTENDED USE TYPE OF WELL <br /> ❑ NDUSTRIAL # ❑ CABLE TOOL Dia. of Well Excavation <br /> ' ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE Gof Casing <br /> 13DOMESTIC/PUBLIC 11 DRIVEN Gauge r <br /> C3 GRAVEL GRAVEL PACK Depth of Grout Seal <br /> 11 IRRIGATION <br /> 1:1CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> ' ❑ OTHER Other Information <br /> 11 DISPOSAL <br /> El GEOPHYSICAL ' /_ ,�yt"It— Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ tate Work Done <br /> PUMP REPAIR: ,, I State Work Done —Y <br /> de <br /> DESTRUCTION OF WELL: , <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> k <br /> 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 /> Horne owner or licensed agent's signature certifies the tollowing:"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:"l certify that in the performance of the work forwhich this <br /> of California." <br /> permit is issued, I shall employ persons subject to workman's compensation laws <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> y Title Date: °( <br /> Signed X _ <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPART NT USE ONLY <br /> PHASE I Date <br /> cFApplication Accepted ByAdditional Comments: I <br /> PIS I Final spection r��y <br /> Phase II Grout Inspection Date <br /> Inspection <br /> Inspection By <br /> k Date Inspection By <br /> I PER UNIT {�'PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY ❑ 7� REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE ` EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> i. PENALTY _ <br /> OTHER - <br /> OTHER - <br /> r 1 <br /> e i <br /> a Mailed Delivered <br /> } Received by Date <br /> Receipt No. Permit a - Issuance D e �,. <br /> 1601 E.HAZELT&AVE.,P.O.Bax 2009 5TOCKTON,C01 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ,- <br />