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p p ations Will Be Processed When SubmittedPropenyc�omple�z�• �� i <br /> APPLICATION ' <br /> FOR OFFICE USE: pUMP&WELL ' <br /> I�lI (For Nan-Transferable, Revocable, 5uspendable) t <br /> J a ' lid ENVIRONMENTAL HEALTH PERMIT <br /> a ilk. i ' WATER QUALITY <br /> I application is <br /> (COMPLETE IN TRIPLICATE) the work. <br /> A lication is hereby made to the San Joaquin Local Health District for a permit to construct ulatd�ons of thle San Joaquin)Local Health District.PP d'. I <br /> made in compliance with San Joaquin County Ord once No. 1862 and the rules g City/Town <br /> Ik, ^ / <br /> f Exact Site'! �I ^ <br /> i <br /> I Illi Phone <br /> Owner's N. met <br /> Cit 3 c_ <br /> Address License'#- �11bI ss Phone �r <br />' Contractors Name I Emergency Phone <br /> Contractor's Address NoT <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? YesR CONDITION❑ DESTRUCT <br /> TYPE OF!: ORK (CHECK): =ELL DEEPEN ❑ PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER PUMP INSTALLATI <br /> REPLAC&AENT❑ I Pit Privy <br /> d 1 I Sewer Lines <br /> DISTANCE TO NEAREST: Se tic Tank Cesspool/Seepage Pit Other <br /> ' Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I : Dia. of Well Excavation <br /> ( I' C3 CABLE TOOL <br /> ❑ INDUSTRIAL I ' Dia- of Well Casing <br /> -11ADOMESTIC/PRIVATE ' ' ❑ DRILLED <br /> fElDRIVEN Gauge of Casing <br /> MN <br /> ❑ DO .ESTIC/PUBLIC Depth of Grout Seal r <br /> 13 IRRIGATION I 13 GRAVEL PACK P <br /> ❑ ROTARY <br /> Type of Grout a <br /> I ❑ CAT SODIC PROTECTION ❑ OTHER Other Information <br /> i 11 DISPOSAL Surface Seal installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> j H.P. <br /> Type of Pump <br /> 51 <br /> II�. ❑ State Work Done <br /> PUMP REPLACEMENT: 141 <br /> PUMP REPAIR: I I State Work Done111,1 <br /> Approximate epth <br /> i DESTRUCTION OF WELL: I i Well Diameter <br /> Describe Material and Procedure <br /> ! ! <br /> i1 I <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin oun y <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 forwhich this permit <br /> is issued, I shall notiemploy 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 folio wing:"l certify that in the performance of the work for which this California.' <br /> permit is issued, I shall employ persons subject to workman's compensation laws of <br /> I <br /> I ill call for a Grout Inspection prior to grouting and a final inspecti '40 <br /> ;W Date- <br /> Title: <br /> Date: <br /> A <br /> Signed..X <br /> ` ly (Draw Plot Plan on everse Side} <br /> FOR DEPARTMENT USE ONLY 9490 <br /> PHASE I <br /> Date ��l <br /> !Application Accepted Be <br /> Additional Comments: I�. Phase IF' Inspection <br /> Phase II Grout Inspection Date <br /> I�, Date Inspection By {' <br /> Inspection By �� <br /> f I ❑ ❑ January i &Rec ived By January 31 ❑ Juiy 1 &Received By July 31' <br /> Fee Is Due: E3 ANNUALLY ❑ PER UNIT ❑ PER SITE EACH REMIT <br /> REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> BILLING <br /> DATE REMITTED AMOUNT <br /> 4il 5- <br /> J <br /> 'FEE ilh <br /> i LESS I�I <br /> ' .PRORATION <br /> P. <br /> :PLUS II <br /> i <br /> ! PENALTY III �Q <br /> OTHER <br /> OTHER 11' <br /> I� f <br /> II <br /> Receipt No. issuance Date Mailed Delivered <br /> IPermit No. <br /> ` I I Received 6y Al! - � 1601 E.HAZELTON AVE.,P.O.Bax 2009 ST <br /> '�t' OCKTON;CA 95201 <br /> r. <br /> APPLICANT—RETURN L COPIES TO: ENVIRONMENTAL HEALTH PERMlT7SEflVICES <br />