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Frop <br /> Applications Will Be Processed WhenSuAPPLIC. ully v <br /> M,c�_ IIPLIC <br /> PUMP&WELL -+� <br /> (For Non-Transferable, Revocable,Suspendable <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> ATE) <br /> Application is hereby made to the San Joaquin Local Health Dis 1862 andtherules and regulattiiioons oftthe San Jkaquinl Local Healltth Distr.This riiict.lication is n 1 <br /> made in compliance with San Joaquin County OrdinanceN R@? City/Town O� <br /> Exact Site Address <br /> L � Phone <br /> Owner's Name [s City <br /> Address a Business Phone-AF-4' <br /> �,�f � fj/I/ License# <br /> Contractor's Name emergency Phone <br /> Contractor's AddressNo <br /> is Certificate of Workman's Compensation Insurance <br /> DEEPEN ❑ith SJL CONDITION❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ '� <br /> Sr Lines Pit Privy � <br /> DISTANCE TO NEAREST: Septic Tank-- Sewer <br /> Pit -te^ Other <br /> Ill. Sewage Disposal Field ; ' <br /> Property Line/+�A Private Domestic Welles Public Domestic Well �f <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation f <br /> ❑ INDUSTRIAL 49 DRILLED Dia. of Well Casing <br /> ���� <br /> N DOMESTIC/PRIVATE [3 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC Depth of Grout Seal <br /> El IRRIGATION '� GRAVEL PACK ���-- <br /> ROTARY Type of Grout .rt _ <br /> ❑ CATHODIC PROTECTION Other Information_ <br /> 13 DISPOSAL ❑ OTHER �� � �p� @i�L/!J �r <br /> Surface Seal Installed By: �--a � <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> 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 /> Home owner or licensed agent's signature <br /> n such manneries the las1togbecome subject to workmany that in the 's compensationnce of the work or which this laws of Cao for ait <br /> is issued, I shall not employ y P <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 prior to grouting and a final inspection. <br /> ® Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FO EPART ENT USE ONLY <br /> PHASE I Date/ <br /> Application Accepted By D <br /> Additional Comments: Phase III Final Inspection <br /> Phase II Grout In pection �L/ r `� inspection By1 Date <br /> Date � <br /> Inspection By . <br /> ❑ PER S4TE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> Fee IS Due: ❑ ANNUALLY ❑ PSR UNIT <br /> REMIT <br /> BILLING <br /> REMITTANCE $ AMOUNT DUE CHECKED BASE EXPLANATIONS DATE DATE REMITTED AMOUNT <br /> FEE •� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER l <br /> 1 <br /> P . <br /> OTHER ]1 <br /> " 73Issnce Date Mailed Delivered <br /> Date Receipt No. <br /> Permit No. <br /> Received by 1691 E.HAZELTON AVE.,P.O.Sam 2009. STOCKTON,GA 9520 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />