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Appltions Will Be When S <br /> icaubmitted Properly <br /> APPLICATION <br /> FOR OFFICE USE: i (for Non-Transferable,Revocable, Suspendable) pUMP &W�tL <br /> :. r <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) <br /> 1 62 and he rules and regulations of the San Jo quin Local Health District. <br /> Application is hereby madetotheSan Joaquin Local Health Distr$t far a permit to construct an dlor install thework.herein described.This aPP <br /> made in compliance with San <br /> Joaquin County Ordinanc4;o City/Town I <br /> Exact Site Address-! Phone ' <br /> 1 <br /> Owner's Name City <br /> Address X' 4 License#I��Business Phone <br /> j Contractor's Name 2 Emergency Phone <br /> No <br /> Contractor's Address IO <br /> I Compensation Insurance on File With SJLHD? Yes <br /> Is Certificate of Workman's Co NEW WELD DEEPEN ❑ RECONDITION 11 DESTRUCTlO❑❑ PUMP REPAIR❑ <br /> TYPE OF WORK (CHECK): ❑ PUMP INSTALLATION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER if <br /> REPLACEMENT❑ 1f Pit Privy <br /> Sewer Lines ^_ Other <br /> DISTANCE TO NEAREST: Septic Tank i Cesspool/Seepage Pit <br /> ► Sewage Disposal field <0I - Public Domestic Well <br /> Property Line+Private Domestic Well ='� <br /> TYPE OF WELL �t <br /> INTENDED USE ❑ CABLE TOOL Dia. of Well Excavation rr <br /> ❑ INDUSTRIAL 13 DRILLED Dia. of Well Casing <br /> )(DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing T <br /> ❑ DOMESTIC/PUBLIC GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout <br /> ROTARY +� <br /> [ E3CATHODIC PROTECTION ❑ OTHER Other Information <br /> [1 DISPOSAL Surface Seal Installed 8y: <br /> ❑ GEOPHYSICAL <br /> Contractor H.P. <br /> 1 PUMP INSTALLATION: Type of Pump <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done <br /> [I State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure a <br /> ordance with San Joaquin County <br /> 1 hereby certify that I have prepared this application and that the work will be done in acc <br /> rules and regulations of the San Joaquin rtiLocal att <br /> ealth District. <br /> ordinances, state laws, and in the performance of the work for which this permit <br /> Home owner or licensed agent's signature certifies the following:" Y <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 for which this <br /> 1 persons s ject to workman's compensation laws of California." <br /> 'F permit is issued, l shall employ p i, <br /> I will ll for a Gro nsp con pr' r grouting and a final inspection. <br /> Date: J� <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse e) <br /> l <br /> Z�a FOR DEPARTMENT USE ONLY <br /> PHASE l Date 3154�&O_ <br /> Application Accepted By <br /> M. Additional Comments: Ph final In action <br /> O�A_ <br /> PhaseGrout In action a Inspection By Date <br /> inspection By <br /> ate <br /> C3 January 1 &Received By January 31 July 1 &Received By July 31 <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER 517E EACH REMITTANCE $ A OUNT DUE CHECKED <br /> BILLING REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> FEE # <br /> LESS <br /> r <br /> PRORATION L' <br /> PLUS <br /> PENALTY <br /> OTHER <br /> f <br /> OTHER <br /> i Issua ce D to Mailed Delivered <br /> Receipt No. Permit No. <br /> Received by Date 1601 E.HAZELTON AVE.,P.O..Bo=2089 STOCK7DN,CA 95201 <br /> ppPLICANT—RETURN'ALL COPIES TO: ._ENVIRONMENTAL HEALTH PERMIT/SERVICES _ .�, <br /> ... ._ <br />