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Applications Will Be Proc—aed When Submitted Property llompierea.ca Quilt i .gal• �••�err••�-••�••• <br /> FOR'efFICE USE: APPLICATION <br /> (For Non-Transferable,Reyocable,Suspetrdable) x <br /> - ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> (COMPWATERUALITY.�LETE IN TRIPLICATE)~ QUALITY <br /> ..Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittdconstruttand/or[nstallthework herein�described,This application is <br /> made in compliance Wiih`ta-n oa in Count Ordin a NP.1 82 a d the rule a regulations of the San Jos, District. <br /> Exact Site Address / yow <br /> City/Town <br /> Owner's Name r r Phone <br /> Address City <br /> Contractor's Name icense Business PI I <br /> Contractor's Address Emergency Phone , t <br /> Is Certificate of Workman's Compensation In,,surraance on File With SJLHD? Yes No t <br /> TYPE OF WORK(CHECK): NEW WELL 9DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP Rfi��}�'�yDlsr p <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank'f Sewer Lines ��� Pit Privy y. <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL `•Z /f G l <br /> ❑ INDUSTRIAL © CABLE TOOL Ala.of Well Excavation �c <br /> VMESTICIPR[VATE �RILLED - Dia.of Well Casing <br /> OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 17 IRRIGATION ❑, AVEL PACK. Depth of Grout Seal <br /> 13 CATH ODIC PROTECTION V ROTARY• Type of Grout_ 1 -� <br /> ❑ DISPOSAL' 0 OTHER Other Information <br /> ❑ GEOPHYSICAL r ; Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ? <br /> Type of Pump H.P. �l <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well'Dismeter_; - Approximate Depth <br /> Describe Material and Procedure <br /> w <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:"-certify that in the performance of the work for which this permit �p <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contracloes hiring or sub-contracting signature certifies the following:'*[certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ]to spection prior to grouting and a final Inspeclfo .- <br /> S :z 101 <br /> igne XTitle: ` Data: <br /> 3 31/ (Draw Plot Plan on Revere Side) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 µA <br /> j Application Accepted By ^� ' - Arco— Date �I r <br /> Additional Comments: <br /> F Ph a II Grout inspection a!nIII Fin Inspection <br /> Inspection By. Date!�t7 4. Inspection 8y Date 3"L� ��/ <br /> l Fee IS Due:❑ AN ALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ .lanuary 1 a Recei d By January 31 Q July 1 d.Reeelved By July 31 <br /> - REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED' AMOUN7,dUE CHECKED <br /> (.,� 2 ( � AMOUNT <br /> FEE 1,J <br /> i LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER 6 <br /> OTHER <br /> 014S S Z <br /> Received by Date Receipi No. Perrrtll_No. lesuance ate I Malled Delivered. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEARTH PEAMrr/$EAVICES 1601 E.HAZELTON AVE.,P.O.Max 2009 STOCKTON,CA 05201 <br />