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Applications Will Be Processed When SuAPtPI.ICATION <br /> daWrAy 8 1981 LLPJJ &wPLL <br /> FSR OFFt�E USE: (For Aloe-Translerabie, Revocagle, i�� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY SAKI J0.hQUIN '-O` described.This application is <br /> (COMPLETE IN TRIPLICATE) ermittoconstrisctanirrlhST��jtb'iLo.cal Health District. <br /> Application is hereby made to the San Joaquin Local Health District a p <br /> App J qui County rd :. O. 1862 and the rules and reguiatioCity/TowenSa q <br /> made in compliance wig v,. .Ver Qal� kCcx• �9 � <br /> Exact Site AddresspgWe Phone ,�-- <br /> Anthony City 1- <br /> Mr. ( a <br /> Owner's Namesame Business Phone-- <br /> Address Water gy5 r?mS License#,� same <br /> MOOrma S - an Phone �J <br /> Contractor's Name C errY Ave• Emergency <br /> Contractor's Address <br /> � Yes,X� No � <br /> ❑ RECONDITION❑ DESTRUCTION <br /> 13 <br /> is Certificate of Workman's Compensation in❑surancDeEoEPEN With SJL IS PUMP REPAIR❑ <br /> TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 13 PUMP IIVSTALLA VIO <br /> 1 W Pit Privy <br /> k REPLACEMENT❑ Sewer Lines Other <br /> Septic Tank Cesspool/Seepage Pit <br /> DISTANCE TO NEAREST. Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well� <br /> INTENDED USE TYPE OF WELL❑ Dia. of Well Excavation <br /> CABLE TOOL <br /> I. Dia. of Well Casing <br /> k ❑ INDUSTRIAL ❑ DRILLED <br /> gDOMESTICIPRIVATE 11 DRIVEN Gauge of Casing <br /> Depth of Grout Seal <br /> DOMESTIC/PUBLIC ❑ GRAVEL PACK <br /> C1, C1 ROTARY <br /> `IRRIGATION Type of Grout <br /> 11 CATHODIC PROTECTION OTHER <br /> Other Information <br /> ir. <br /> _ TtdypStt <br /> Surface Seal Installed ay: <br /> ❑ DISPOSAL rS tems; SWate <br /> ❑ GEOPHYSICAL Moorman <br /> actor <br /> H.P.P <br /> ible <br /> PUMP INSTALLATION:. g m r <br /> k of Pump <br /> ate <br /> w <br /> Work DoneB� <br /> PUMP REPLACEMENT. ❑ State Work Done Approximate Depth <br /> PUMP REPAIR: Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure rte <br /> eared this application and that the work `^�Ilibe HeaRh District cordance with San Joaquin County <br /> I hereby certify that 1 have prepared <br /> ` ordinances, state laws, and rules and regulations of the San Joaquin Local <br /> following: ch <br /> „ certify ensation flaws of California." <br /> rrte owner or licensed agent's signature certifie mannerhe as to becomsubject to workman's compennce of thesation <br /> ati heowo kl for wlh h this <br /> kNo person in such <br /> 1 is issued, i shall not employ any P Ing: I certifythat in the performance o t <br /> Contractor's hiring h ll employ <br /> perng sonsnature to tifies the workman's lieompensation laws of California." <br /> 1. permit is issued, 1 shall employ p / <br /> k i will call for a Grout inspection prior to grouting and a final inspection. pate: / <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> Date <br /> PHASE I <br /> ` Application Accepted By <br /> Additional Comments: a III Final Inspection <br /> Phase 11 Grout Inspection pate <br /> Inspection I3y <br /> J Date y <br /> inspection By JuVy 1 &Received By July 31 <br /> ❑ January 1 &Received By January: ❑ REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REM4TTED AMOUNT <br /> ` BASE EXPLANATION DATE DATE c @� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ,r - <br /> OTHER <br /> t <br /> OTHER E C z <br /> c� led <br /> u Detivered <br /> Mai <br /> Is u nce Da <br /> Permit No. <br /> Date Receipt No. - - 1601 E.HAZELTON AVE-,P.O.Box 2009 STOCKTDN,CA 95201 1 <br /> Received by —RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMITlSERVICES <br /> APPLICANT <br />