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'ter Y AprG <br /> EPPll'CCe9sed4hVIAPPLICATION <br /> Emitted Properly Completed. Be SureToSign TneAppilcauon. <br /> - " <br /> fU i t7rnyr. uOe: �g�Non-Transferable, Revocable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAN JOAQUIN LOCAL WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) UM6TH FIST ] T <br /> Application is herebymadetothe q u I n oc T19 hDistrictforapermittoconstruct and/or install the work herein described.This application is <br /> made in compliance with v�San Joaquin County Ordinance No. 186;and the rules and regulations of the SarJoaquin �l Health District. <br /> Exact Site Address <br /> / 5' . 1 T N /Zp� City/Town <br /> �. 4 vL Phone <br /> Owner's Name „6� <br /> _ <br /> City <br /> Address ��d 7 <br /> Contractor's Name -s �/ Licensev3iiPhone !I, <br /> ness <br /> Emergency Phone <br /> Contractor's Addres .,■ <br /> /+�I�� S�, <br /> s <br /> l� IO <br /> Is Certificate of Workman's Compensation Insurance on Fiie With SJLHD? Yes } <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER 11 , PUMP INSTALLATION ❑ PUMP REPAIR El t <br /> REPLACEMENTS <br /> DISTANCE 70 NEAREST: Septic Tank <br /> Sewer Lines Pit Privy y 1 <br /> Sewage Disposal Field 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 /> 1-1 DRILLED Dia. of Well Casing <br /> DOMESTIC/PRIVATE <br /> ❑ DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ,V <br /> ❑ CATHODIC PROTECTION ❑ ROTARY _ Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> i El GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: IN State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> fApproximate Depth <br /> C DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <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 /> 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, 1 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:"I certify that in the performance of the work for which this <br /> i permit is issued, I shall employ persons subject to workman's compensation laws of California." F <br /> I will c I for a Grout 1 Ilion rior to grouting and a final inspec ISPkg <br /> Title: �'^ > Dale: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side} <br /> i <br /> RD PARTMENT USE ONLY <br /> rPHASE I Date 7 v <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout inspection a` IFI a1 Inspectio <br /> Inspection By Date <br /> Inspection By Date <br /> q Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i & eived By January 31 ❑ July 1 &ReceiveRdEByl July 31 <br /> IIY BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> LBASE EXPLANATION DATE DATE {{REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No. Permit No Issuance Date Mailed Delivered <br /> ate <br /> Received by - 1601 E.HAZELTON AVE.,_P.O.Boa 2009 STOCK-rom CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />