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„..Applications Will Be Processed When Submitted Properly Completed. Be u 4 <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pUMP&WELL ` <br /> ENVIRONMENTAL, HEALTH PERM T <br /> 1,5 0 !J t WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) C--a, j + <br /> Application is hereby made to the San Joaquin Local Health District for a permit toconstruct and/or install thework herein described.This application is <br /> made in compliance wit San Joaquin Count/y Ord' o. 186 d the rules and regulations of the San Joaquin Local Health District. <br /> City/To77S <br /> Exact Site Address 7Q <br /> Phone ! a <br /> Owner's Name ! City <br /> Address _ Business Phone 1 Ljcens ` <br /> Contractor's.Name Cv <br /> Emergency Phone � I' <br /> Contractor's Address er- No q� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes vt <br /> TYPE OF WORK (CHECK): NEW WELL 19—"DEEPEN ❑ RECONDITION 13 DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13OTHER ElPUMP INSTALLATION REPAIR 13 i <br /> REPLACEMENT❑, Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> ` sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line 9) Z_/Private Domestic Well - - _Public Domestic Well. �1 <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ng Z <br /> 0-MMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11DOMESTIC/f DOMESTIC/PUBLIC Cl DRIVEN Gauge of Cassing ^� # <br /> 11 IRRIGATION ' 11 GRAVEL PACK Depth f Grout <br /> Grout Seat � <br /> 1:1 CATHODIC PROTECTION &TtOTARY Type of j <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump } H P. <br /> PUMP REPLACEMENT: ElState Work Done <br /> E PUMP REPAIR: 1:1 State Work Done "'I <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter— <br /> Describe <br /> iameter Describe Material and Procedure <br /> f <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County J <br /> _ ordinances, state laws, and pules and regulations of the San Joaquin Local Health District. <br /> i. <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, 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:"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 <br /> Il for Grout Inspection. <br /> prior to groutin and a sinal inspection. <br /> Date: <br /> Signed X <br /> -�- ,,�,�t,,.,r .� Title: } <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY - <br /> PHASE I Date kip � <br /> If Application.Accepted y <br /> Additional Comme s: <br /> P e 111 Final Inspection <br /> Ph se II Grout lte Inspection B ns Da ` y Date <br /> i � Date ! <br /> Inspection By �— <br /> E <br /> E] July 1 <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT 13 PER SITE ❑ EACFI' ❑ January 1 ii Received By January 31 &ReceivedREMIT <br /> uIy 31 <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> p I <br /> FEE SB � ~� <br /> LESS <br /> PRORATION <br /> I PLUS <br /> + PENALTY <br /> Y.. <br /> OTHER <br /> OTHER <br /> L � <br /> LDate . Issuance D te, Matted Deiivered <br /> Received by - Receipt No. Permit No1601 E.HAZELTON <br /> APPLIC TAYE.,P.O.Boy 2009 STOCKTON,CA 95201 <br /> + —RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />