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f <br /> " rBe Processed <br /> Applications Will When Su APPLICATION endable) pump &WELL <br /> Y �F~p OFFICEX SE: ter.„,,yp (For Non-Transferable,Revocable,Susp <br /> �© 9 ENVIRONMENTAL HEALTH PERMIT <br /> ' `•'�- QUALITY Ilcation,is <br /> WATER <br /> ions of the San Joaquin L c 1 Health District. <br /> KATE) Health District#or a permit to construct and/or install the work.herein described.This ap <br /> (CO PLETE IN TRIPL a rules and regulat 7 <br /> made to the SanJoaqulnLoOrdinanceNo. 1862and City/Town 1 ��rr rvD, <br /> Application is hereby Joaquin County <br /> made!n compliance with Sante �� <br /> phone . <br /> Exact Site Address j City <br /> !,V Business Phone <br /> Owner's Name License# 7 <br /> I Address ' Emergency Phone J 4 <br /> �t No <br /> Contractor's Name �ith SJLHD? Yes r" <br /> Contractor's Address ❑ DESTRUCTION❑ <br /> DEEPEN RECONDITION ❑ PUMP RE <br /> PAIRi <br /> Is Certificate Of WorX K)Compensation on File OTHER ❑ PUMP INSTALLATION <br /> TYPE OF WORK (C ❑ WELL ABANDONMENT <br /> WELL CHLORINATION Pit Privy Other <br /> l Sewer Lines <br /> REPLACEMENT❑ septic Tank Cesspool/Seepage Pit <br /> DISTANCE To NEAREST. Sewage Disposal Field Public Domestic Well <br /> Property Line�Private Domestic <br /> TYPE OF WELL Excavation <br /> I . Dia. of Well <br /> I INTENDED USE ❑ CABLE TOOL <br /> Dia. of Well Casing <br /> ❑ INDUSTRIAL ❑ DRILLED Gauge of Casing <br /> DOMESTIC/PRIVATE ❑ DRIVEN Depth of Grout Seal <br /> v <br /> r ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Type of Grout <br /> j ❑ IRRIGATION ❑ ROTARY <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> Surtace Seal Installe Yi <br /> ❑ DISPOSAL- <br /> El <br /> ISPOSAL❑ GEOPHYSICAL Contractor 0 H.P. <br /> �l PUMP INSTALLATION: Type of Pump . <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: State Work Done Approximate Depth <br /> ` PUMP REPAIR: <br /> Well Diameter <br /> I DESTRUCTION OF WELL: Describe Material and Procedure <br /> I <br /> t this application and that the-work will be done in accordance with San Joaquin Coun y <br /> 1 hereby certify that I have preparedulPP11 of the San Joaquin Local Health District. <br /> ork <br /> t ordinances, state laws, <br /> and rules and reg I certify that in the performance of the 0 tion law Of this permit <br /> Home owner or licensed agent's signature certifies the following:,. that o the performance of the work for which this <br /> an person in such manner as to become subject to workman's compensation laws of California. <br /> is issued, 1 shall not employ Y P <br /> I signature certifies the following-nsaton laws of California." <br /> Contractor's hiring or submploy pe sons subject to workman's comp <br /> per . is issued, I shall employ P <br /> r4 grQutin nd a f' of inspection. Date: <br /> call for a Grou <br /> 1n o Reverse Side) <br /> Signed ( raw Plot <br /> FOR DEPARTMENT USE ONLY <br /> Date 1� <br /> PHASE I " f <br /> I Application Accepted By Phase Ili Final Inspection <br /> Additional Comments: Date <br /> Phase if Grout Inspection Inspection BY <br /> I Inspection By Date _ 31 �] .iuiv ti a Received By July st <br /> ❑ January 1 &Received By January REMIT <br /> PER UNIT ❑ PER SITE ❑ EACH $ AMOUNT DUE CHECKED <br /> Fee^IS Due: C1 ANNUALLY ❑ BILLING REMITTANCE REMITTED PATE AMOUNT <br /> D <br /> [ BASE EXPLANATION DATE <br /> FEE _ ✓ Cq <br /> LESS ,,�, -do <br /> PRORATION ? � <br /> i CtilfUfl-r) �r�"' <br /> PLUS ^< [ 1 r h <br /> r PENALTY <br /> 6 I / <br /> t 'Jf f V <br /> 0 <br /> OTHER L' L <br /> U yt ys � v+,,..i l I �ro es/4 <br /> OTHER �sJ c 4 iSl Lrv� T,Y 1 _ r'Z <br /> 4r Mai Delivered f <br /> t r jinJf�tL>4�Y1�' ssuance ate <br /> Permit No STOCKTO <br /> Date Receipt No. 1501 E.HAZELTON AYE.,P.O.BOX 2408 =_ <br /> Received by Y ENVIRONMENTAL HEALTH PERMITISERVIGES <br /> APPLICANT—RETURN ALL COPIES TO: ,. g <br />