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Applications Will Be Processed When Submitted Properly ow �ur� r ...y • ••• rr <br /> FUH O <br /> _��` "�` (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> 4' -ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> FAppliciation E IN TRIPLICATE} in toca4 eal h District. <br /> I is hereby;'I <br /> deto the San Joaquin Local Health District for permit and r c ulatdaoons oftheSanagerein described.This application is <br /> - C <br /> mpliance h San Joaquin oun y Ordin2lnc No• 1862 7 City/Town -� <br /> Exact Site Addresses ! ` / !/ <br /> ! G'l � ' C.-"�✓ '�' f> r Phone <br /> [-' <br /> Owner's Name_ / City f p(a <br /> Address ' <br /> License# S �/ Business Phone <br /> Contractor's Name Gt7 Emergency Phone } <br /> !• No <br /> Contractor's Address � Yes <br /> Is Certificate of Workman's Compensation Insurance on File With SR CONDITIDN❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELLS DEEPEN C• <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ rPUMP INSTALLATION'S PUMP REPAIR❑ _- <br /> W ; <br /> REPLACEMENT❑ �r/� f 74 Pit Privy <br /> �G�L� 7t Sewer Lines S Other <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit ,M <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line ILI" f Private Domestic Well f id <br /> TYPE OF WELL / Q <br /> INTENDED USE pia. of Well Excavation fr <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> Dia. of Well Casing <br /> K�+DRILLED <br /> DOMESTIC/PRIVATE 13 DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC Depth of Grout Seal <br /> � ❑ IRRIGATION 11 GRAVEL PACK <br /> ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> 11 DISPOSAL �. .' <br /> Su,face Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor - H.P. „ <br /> PUMP INSTALLATION: z <br /> Type of Pump <br /> [IState Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: I <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application <br /> the San t the Joaquin willbe Local Healdone in District,accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulate _ <br /> Home owner or licensed agents signature certifies the following:"I certify that in the performance of the work for which this permit 4 <br /> is issued, I shall not employ any person in such manner as to become 1 certify to workman's <br /> nrthe perfoompensation rmance of helwork forwhiich this <br /> Contractor's hiring or sub-contracting signature'certifies the Collo g <br /> permit is issued, I shall emipl f persons subject to workman's compensation laws of California." ` <br /> I will dr a _o/ut Ins e on pr routing-and,a final inspeci1..oh. l _ <br /> d � Jr Date: Cl <br /> a _ Title: k F . <br /> Signed X - ~r <br /> t <br /> (Draw Plot Plan on Reverse Side) <br /> ' f fFORD PARTM NT USE ONLY <br /> _ Date f - <br /> PHASE I ! <br /> Application Accepted By <br /> Additional Comments. Phase ill Final Inspection <br /> Phase It Grout Inspection ^` Inspection By Date <br /> Inspection By <br /> Date <br /> _ ❑ January t &Received By January 31 ❑ July &Received 6y July 3? <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT F-1 PER 517E El $ AMOUNT DUE CHECKED <br /> _ BILLING REMITTANCE REM4TTED AMOUNT <br /> BASE, EXPLANATION DATE BATE <br /> I FEE ! !' <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> i <br /> OTHER b�� <br /> -n s00 <br /> Receipt No. Permit No <br /> Issuance Date Mailed Delivered <br /> Received by Dat _ 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br /> --APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM4T75ERYlCES _ - <br />