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Applications Will Be Processed When Submitted Properly Gompieiea. oeoure iv aiit 1 _Vr•�• <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY 22Z�--070-02_ <br /> (COMPLETE IN TRIPLICATE) It t/�5 I <br /> Application is hereby madeto the San Joaquin Local Health District fora permitto construct and/or install thewor.k herein described. D This cation is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and re ulations of the San Jo quin Local Health District. <br /> � 51� S k oNw r Sao- City/Town _I <br /> Exact Site Address,_ /(] \ �yCs'— <br /> PJJ Phone a <br /> Owner's Name Chi <br /> l City� �hf _� <br /> Address <br /> License#. easiness Phone <br /> Contractor's Name <br /> �, �,� ` o,y Cf�, yy� -Emergency Phone _ -� <br /> Contractor's Address _ No ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes__- <br /> I TYPE OF WORK (CHECK): y NEW WELL 13 DEEPEN ❑ RECONDITION C3 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 OTHER ❑ PUMP WSTALLATION� PUMP REPAIR❑ <br /> REPLACEMENT❑ i <br /> Sewer tines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank - <br /> Other <br /> Cesspool/Seepage Pit ' <br /> Sewage Disposal Field ; <br /> Property Line Private Domestic Well Public Domestic Well z <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavations <br /> DOMESTIC/PR[VATE 11DRILLED Dia. of Well Casing <br /> ±`V <br /> C1DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing - <br /> ❑ IRRIGATION <br /> I 13 GRAVEL PACK Depth of Grout Seal w <br /> �'-•• _.. <br /> t <br /> E] CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> 13 DISPOSAL <br /> f ❑ OTHER Other Information - <br /> 11 GEOPHYSICAL ' e Surface Seal Installed By: <br /> PUMP INSTALLATION:; Contractor <br /> ` Type of Pumper H.P. <br /> l PUMP REPLACEMENT:; ❑ State Work Done <br /> ❑ State Work Done <br /> PUMP REPAIR: - <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter �t <br /> I , <br /> Describe Material and Procedure <br /> } <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:"I certify that in the performance of the work for which this permit <br /> t 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 for which this <br /> F permit is issued, I shall employ persons subject to workman's compensation laws of California." O <br /> I will call fora Grout Inspection prior to grouting and a final inspection. <br /> Title: Date: <br /> Signed X -� - <br /> (Draw Plot Plan on Reverse Si e) _ <br /> I �'ORD PARTME T USE ONLY <br /> PHASE I � - Date -//��IiIj�l <br /> Application Accepted By <br /> Additional Comments: <br /> Phase tl Grout Inspection Ph ItFtnal I spection � <br /> Inspection By Date Inspection By Date <br /> 1 Fee IS Due: ❑ ANNUALLY ❑ PERIUNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jul eceiv REMITuly 31 <br /> L <br /> BASE EXPLANATION BILL$NG REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> AI�5 <br /> FEE <br /> I LESS <br /> PRORATION <br /> PLUS ' <br /> I PENALTY _ - <br /> OTHER <br /> OTHER <br /> �—y a10�5 9 tq 79 <br /> Date Receipt No. - f Permit No. s Issuance Date Mailed Delivered- <br /> Received by- <br /> APPLICANT—RETURN ALL COPIES TO: ENYIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA.95201 - � <br />