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Applications Will Be Processed When Submitted Properly Cornplee <br /> FOR.OFFICE USE: APPLICATIO <br /> (For Non-Transferable, Rey oc IIea�iie} PUMP&WELL <br /> .. s .. �- MENTAL HEA PEM7 <br /> 198 <br /> _r ENVIRON M7 <br /> (COMPLETE IN TRIPLICATE) WATER QUALIT q� 'a�- '� <br /> Application is hereby madetotheSan Joaquin Local Health Districtforapermit toconstruct and/or�ir'�st�f1:'the ! lirrim described,ThisappSicationis f <br /> made in compliance w.ith San Joaquin unty rdinance o. 1 2 and a rules and re I 17f <br /> a In Local Health District. <br /> {� pTown <br /> Exact Site Address d- 4 <br /> I <br /> Phone <br /> Owner's Name City <br /> Address Business Phone 6 a <br /> Contractor's Name � '-� � License# ��� <br /> Contractor's Addresses Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yesy <br /> No i <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONp1TIQN❑ DESTRUCTION❑ <br /> WELL CHLORINATION C3WELL ABANDONMENT El OTHER 1:1PUMP INSTALLATION❑ PUMP REPAIR❑ �y <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property tine Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> of Well Excavation <br />�_ 11 INDUSTRIAL -� - 0'�CABL-E TOOL-"""'-""`"- -Dia, , <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> _ �❑-DRIVEN Gauge of'Casing <br /> 11 DOMESTIC/PUBLIC— * <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br />* ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑•GEOPHYSICAL Surface Seal Instal ed By: <br /> t PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump ; <br /> PUMP REPLACEMENT: Mate Work Done { <br /> PUMP REPAIR: ❑ State Work Done T <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> Approximate Depth <br /> i <br /> ., Describe Material and Procedure , <br /> I hereby certify that I have prepared this application and that the work wiii be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> • <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performarice of the work for which this permit <br /> is issued, I-shall not employ-any-person in such manner as to become subject-to work man's'•compensation laws of California." <br /> ( Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performancefef the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi all or a Grou Inspection pri to grouting and a final inspection." a' <br /> Date: <br /> Signed X -Title: <br /> 't (Draw PI t Plan on Revere Side) <br /> 1 FOR DEPARTMENT USE ONLY ' <br /> PHASE 1p �` + Date 1�� <br /> Application Accepted By VVW��EIII��N y <br /> I Additional Comments: . ~ <br /> ase-11 i a Inspection (� <br /> Phase II Grout inspection I <br /> Date Inspection By. T <br /> Inspection By ✓^; _ ;.. � -r '^i <br /> I <br /> Ju}y 1 &Received y Y 31 v. <br /> �t Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE E1 EACH ❑ January 1 &Received ap January 31 ❑ REMIT <br /> uI <br /> F I BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> BASE h EXPLANATION DATE DATE REMITTED' AMOUNT <br /> iv,�" <br /> s FEE i7� r <br /> f <br /> I LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 <br /> - <br /> Date Receipt No. Permit No, - Iss ance ate Mai4ed De4ivered <br /> Received by <br /> : 1601 E.HAZELTON AVE-,P.O.boa 2009 STOGKTON,GA 95201 <br /> 'APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> " _ r <br />