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Applications Will Be Processed When Submitted Properly omp e e . <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL , <br /> ENVIRONMENTAL HEALTKPERMIT <br /> WATER QUALITY ,� <br /> (COMPLETE IN TRIPLICATE) <br /> I Application is hereby made to the San Joaquin Local Health Districtforaper mittoconstructand/onnstalltheworkhereindescHealtThitrict.cationis <br /> made in compliance witty San Joaquin C rtty Ordinance No. 1862 and the rules and regulations of fYie San Joaquin Local Health District. <br /> qe'" tiEw�,c �. City/Town <br /> Exact Site Address <br /> �-7� " i _ Phone• <br /> ' Owner's'Name �✓0 7!1tiu: <br /> � ..,-, City <br /> Address <br /> License# <br /> ,° ,« Business P,honer" <br /> Contractor's Name . •� s:. + <br /> � ..,-► , .,r.: , , 'Emergency Phones <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF-WORK (CHECK): - NEW WELL -`- "DEEPEN ❑ RECONDITION❑ - DESTRUCTION% <br /> WELL,CHLORINATION 13WELL ABANDONMENT 13 OTHER ❑ PUMP INSTALLATION® PUMP REPAIR 13 <br /> REPLACEMENT❑' Pit Privy <br /> DISTANCE TO NEAREST: r Septic Tank Sewer Lines <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well <br /> Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ II){0 1�STRIAL ❑ CABLE TOOL pia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> ET DOMESTIC/PRIVATE Gauge of Casing <br /> 11DOMESTIC/PUBLIC C3 DRIVEN 6 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> El DISPOSAL <br /> 1:1 OTHER Information <br /> OTHER ' <br /> _ Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. (b <br /> PUMP REPLACEMENT: ❑ State Work Done - <br /> PUMP REPAIR: <br /> 11 State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure <br /> I hereby certify that 1: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 /> 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 forwhich this <br /> permit is issued;I shall employ persons subject to workman's compensation laws of California."r' <br /> twill call for a G rout.Inspection prior to-grouting and a final inspe ' n. <br /> Title: f — Date: Cn / �'✓ r <br /> Signed X I (Draw Plot Plan on Reverse Side) <br /> r - <br /> FOR DEPARTMENT USE ONLY / <br /> PHASE I { T' - DateJ` <br /> Application Accepted By <br /> Additional Comments: _ <br /> Phase It Grout Inspection Pas final Inspection " r 7, 3�1 <br /> Inspection By <br /> Date Inspection By Date_ �J T <br /> Fee Is Due: ❑ ANNUALLY [TPER UNIT IJ SITE- ❑ EACH -- El January 1 R Received By January 30 C1 July 1 8 Receiir July 31 <br /> REMIT <br /> BILLING REMITTANCE. $ AMOUNT DUE CHECKED <br /> BASE —EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE I,. <br /> LESS <br /> PRORATION 4 - <br /> PLUS - <br /> PENALTY <br /> - <br /> OTHER ' <br /> OTHER <br /> ace Date Mailed ; Deliyered� . . <br /> ' Receipt No Permit No, - r, -. r' <br /> Received by -" -� +� Date._ "- 7g01 E..HAZELTON AVE.,P.O.aoK 2609 $TOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES — - <br />