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mppncatlonsWill BeProcessed When Submitted Properly Compl t �` <br /> FOR OFFICE.USE: APPLICATION B a '4e agp[i t n. J <br /> ! (For Non-Transferable Revocable, - <br /> SuspendabIC T 1 0 1979 PUMP&WELL <br /> (� <br /> I ENVIRONMENTAL HEALTH PERMIT.4 r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN❑❑f►O��-AQUI!N LOCAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/y�gt�1 I4 wel'Idl'feWjQ J t <br /> made in compliance with San Jo quin Cou ty r inane No. 1862 an th rules and regulations of the SapJo uinlLocal Health District.iapplication is <br /> Exact Site Address�L _ �t r <br /> f- t� I° City/Town _ <br /> Name <br /> /L <br /> ! Owner's N <br /> Address � i Phone - <br /> Contractor's Name <br /> License# �-J� Business Phone �f���J� <br /> Contractor's Address <br /> mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_ <br /> I TYPE OF WORK (CHECK); NEW WELL -DEEPEN ❑ RECONDITION 0' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONM <br /> REPLACEMENT❑ PUMP REPAIR❑ <br />_ DISTANCE TO NEAREST: Septic Tank! ` ` <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> perty,Lirie Other <br /> Pro -;W Private Domestic-Well Public Domestic Well <br /> INTENDED USE r <br /> ❑ INDUSTRIAL TYPE OF WELL <br /> ❑ CABLE TOOLfl <br /> Dia. of Well Excavation <br /> DOMESTIC/PRIVATE <br /> ❑ DRILLED Dia. of Well Casing ff <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION Gauge of Casing <br /> 13 GRAVEL PACK Depth of Grout Seal <br /> 13 CATHODIC PROTECTION l <br /> 11 DISPOSAL ROTARY Type of Grout <br /> 1:1 GEOPHYSICAL <br /> GEOPHYSICAL Other Information _ <br /> PUMP INSTALLATION: Surface Seal Installed By; C <br /> Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR' ❑ State Work Done 41 i <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure Approximate Depth <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 /> Home owner or licensed agent's signature certifies the following: <br /> is issued, i shall not employ any person in such manner as to blf performance <br /> eof the compensation f laws risCalifornia." <br /> this <br /> mit <br /> ecomesubject to workman's <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 bcall for a Groy Inspection prior to grouting and a final inspection. <br /> Signed X s + <br /> Title: Date: <br /> (Draw Plot Plan on Reverse de)-� <br /> FOR DEPARTMENT USE ONLY <br /> PHASEf , <br /> Application Accepted By 6/7Additional Comments: ( Date al f <br /> Phase ill Grout Inspection <br /> t <br /> Inspection By / has III Final Inspection <br /> Date U ,7 _ Inspection By Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT IEC PER SITE ❑ EACH <br /> ❑ January 1 R Received By January 1. ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED' '4 <br /> FEE AMOUNT <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> x <br /> OTHER <br /> �-7 3 <br /> Received by — Date Receipt No. — 5 <br /> APPLI <br /> P Permit No, -Issuance Date Mailetl <br /> CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Delivered <br /> _ —.— -1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTniu cA nevee <br />