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Applications Will Be Processed WhenSubmitted ProperlyCompletellMbinWMyn <br /> F' R' <br /> OFFICE USE: ,.APPLICATION <br /> a n-Transferable, Revocable,Sus e) 1979 �] <br /> Ta,, .: I (For No AUG8 PUMP&WELL <br /> � a <br /> f 7 ENVIRONMENTAL HEALTH PERMIT S <br /> WATER QUALITY SAN .�OI�Q(. IN R 17 .AL <br /> (COMPLETE IN TRIPLICATE)} P��5essc bod.This application is <br /> Application is hereby made to the S' Joaquin Local Health Districtfora permit to construct and/or in <br /> made in compliance with S n Joaq' in County Ordina No 1862 and the rut a d regu tions of the San oaquin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> `` Phone <br /> Owner's Name <br /> Cit <br /> II Y <br /> Address <br /> Contractor's Name <br /> o License#� Business Phone <br /> Con'ractor'sAddress _�e n� Emergency Phone � <br />'i Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _— No <br /> TYPE OF WORK (CHECK): NEW WELL' DEEPEN ❑ RECONDITIONED DESTRUCTION❑ ` <br /> WELfL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION - PUMP REPAIR C] <br /> REPLACEMENT❑ ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal <br /> Field Cesspool/Seepage Pit � -- = Other <br /> Property Line-. ,Private Domestic Well J\DA Public Domestic Well 4 <br /> h INTENDED USE 'i i TYPE OF WELL- <br /> ❑ INDUSTRIAL H, �-CABLE TOOL Dia. of Well Excavation �y <br /> C&DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I' 13DRIVEN Gauge of Casing .� <br /> ❑ DOMESTIC/PUBLIC it ❑ GRAVEL PACK Depth of Grout Seal r <br /> 1 ❑ IRRIGATION Type of Grout S� <br /> F ❑ IICATHODIC PROTECTION �; E] ROTARY Yp ---� <br /> © IDISPOSAL 11OTHER Other Information <br /> 1 <br /> h T Surface Seal Installed 8y: <br /> ❑ GEOPHYSICAL �� <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done j <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth <br /> 3 i 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 certifies the following:"I certify that in the performance of the work for which this permit. <br /> subject to workman's compensation laws of California. <br /> is issued, I shall not employ any person in su " <br /> ch manner as to become <br /> I Contractor's hiring or sub-contracting signature certifies the following:' certify that in the.performance of the work for which this <br /> permit is issued, I shali 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 /> 111 <br /> Signed X <br /> Title:_ Date: <br /> (Draw Plot'Plan on Reverse Side) <br /> F R DEP TMENT SE ONLY i <br /> PHASE I '� W `' t t <br /> �r-�F bate <br /> Application Accepted By <br /> Additional Comments: ''. <br /> I - � h se IH Final Inspecti n t <br /> Phase II Grout Inspection �y <br /> Irtspection-By—r-�.- <br /> Dates ' �7 Inspection By ate <br /> r Fee Is Due: 0-ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Ju+y 1 &ReceiveREMlTd By uly 37 <br /> I ILL+ REMITTANCE .$ Vii' <br /> 131LLkNGAMOUNT DUE " CHECKED_ ' <br /> _.. BASE EXPLANATaI-ON..r ­.-pATE DATE REMITTED AMOUNT <br /> FEE .�.--..' <br /> LESS <br /> i I PRORATION - - <br /> PLUS 1 I <br /> PENALTY I <br /> OTHER <br /> i OTHER •-.Y _. v.. <br /> f <br /> Pate Receipt No. Permit No. issuance Date Mailed Delivered <br /> Received by - <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PEAMITlSERVICES .1601 E.HAZELTON AVE.,AYEP.O.PO 'Box 2009 S70CKTON„CA 95201 <br />