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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. i <br /> FOR OFFICe,USE: APPLICATION <br /> } �-- (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY _ " <br /> Application is hereby made to the San Joaquin Local Health District fora permittoconstruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordi ante No. 1862 and he rules and regulations of the San Joaquin Local ealth District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address $ OQ "^ City <br /> Contractor's Nam 016e ' 0 &9S Business4P.hoone 4 <br /> Contractor's Address r' Emergency Phone s1_tr ��+ - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): 'NEW-WELL 0-- DEEPEN El -RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> REPLACEMENT❑ Ic— <br /> ! .] Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank 7,- "7_ Server Lines Y <br /> Sewage Disposal Fie Cesspool/Seepage Pit 4-OU-9— Other +—�— <br /> Property Line_/ Private Domestic Well Public Domestic Well �-1 <br /> INTENDED USE TYPE OF WELL t `� <br /> ❑., INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> 0�DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC -IJ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑.bRA�VEL PACK Depth of Grout Seal <br /> Type of Grout l <br /> El CATHODIC PROTECTION I�ROTAfiY k Yp <br /> ❑ DISPOSAL _. OTHER <br /> Other Information <br /> ❑ GEOPHYSICAL Sur ace Seal installed By: <br /> PUMP INSTALLATION: '^Con,r`actor O <br /> Type of Pump . H.P. <br /> PUMP REPLACEMENT: ❑,State Work Done <br /> PUMP REPAIR: 11State W ro k.Done <br /> Approximate Depth + <br /> DESTRUCTION OF WELL: i Well Diameter M y a <br /> # Describe Material and Procedure 4 <br /> 3 I hereby certify that I have;prepared this application and that thet.work1will, 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 performanceof the work for which this permit <br />'I 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 orsub-contracting signature In the following :"I certify that in the performance of the work for which this <br /> ermit is issued, I shall employ er s sublect to workman's compensation laws of California." s <br /> r to ut' and a final inspection. ; <br /> ' call for a Grout s p 9 <br /> i� <br /> Signed X Title: Date: <br /> 4 (Draw Plot Plan on Reverse Side) <br /> ,5 <br /> } <br /> F9R DEPARTMENT USE ONLY <br /> PHASE I <br /> i Date <br /> Application Accepted By <br /> Additional Comments: t <br /> e <br /> P �jlna�il'tnspecfion <br /> Ph I out Inspection i� 7 / <br />{ Inspection Dat Inspection By Date l <br /> i ' <br /> w <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT-`,""-13,PER"SITE ----E1 EA'CH c ❑ Januaryf 1 &Received By January 31 July 1 &Received By July 31 <br /> r'!-.- - REMIT <br /> _ <br /> BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> BASE ' EXPLANATION DATE , DATE REMITTED AMOUNT <br /> i - <br /> FEE <br /> LESS <br /> PRORATION r - <br /> PWS <br /> PENALTY. r r <br /> OTHER <br /> OTHER <br /> y <br /> Received <br /> Date Receipt No. ermit No. issuance ate Mailed Delivered <br /> -. - I - W ` <br /> "� " 1601 E.HAZELTON AVE.;P.O.Box-200 5TOCKTON,GA 45201 <br /> APPLt NT—RETURN ALL COPIES TO: ENVIRONMENTAL H�TH PERMIT/SERVICES',,�``� R W ,� � i1 <br />