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Applications Will Be Processed When Submitted Properly Completed. Be Sure Iooi9n 111^vF•�••• L <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pUMp&\JI <br /> ENVIRONMENTAL HEALTH PERMIT Z <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> cal Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Lo <br /> e No. 1862 and the rules and regulations of the San JoaquiLocal Health District. <br /> made in compliance with San Joaquin County Ordinanc <br /> 0 City/Town <br /> Exact Site Address ..W <br /> Phone <br /> D e S <br /> Owner's Name b T- City <br /> Address3s —�4�� <br />` Contractor's Name E` License# 7 Business Phone_ <br /> CJ Emergency Phone <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insurance on File ith SJLHD? Yes 0 <br /> DESTRUCTIONO <br /> TYPE OF WORK (CHECK): <br /> WELLY ABANDONMENT ❑DEEPEN ❑ OTHER RECON❑DITTO SOP INSTALLATIONJK PUMP REPAIR❑ ) <br /> WELL CHLORINATION _ <br /> REPLACEMENT❑ Pit Privy l�1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Field i <br /> Property Line Private Domestic Well Public Domestic Well � <br /> INTENDED USE TYPE OF WELL <br /> [1 INDUSTRIAL <br /> N❑ CABLE TOOL Dia. of.W211 Excavation <br /> ❑+:DRILLED Dia. of-Well Casing <br /> i DOMESTIC/PRIVATE ElDfUEIV Gauge of-Casing <br /> ElDOMESTIC/PUBLIC lk_tc <br /> '4 El I GRAV�EL PACK Depth_of(Grout Seal <br /> 13 IRRIGATION a.) <br /> 11F,IOTAR Type..of Grout <br /> 13 CATHODIC PROTECTION <br /> 13 DISPOSAL ❑ OTHER StQr Information <br /> ❑ GEOPHYSICAL l� Q,Surfa�5eal installed By: <br /> Contractor S <br /> PUMP INSTALLATION: t H.P. � <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Don <br /> I Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL, <br /> - Describe Material and Procedure <br /> f ' <br /> I hereby certif that 1 have prepared this applliication and that the work will be done in accordance with San Joaquin County <br /> I ordinances, sta a laws, and rules and regulati_onts ofithe San Joaquin Local Health District. <br /> Home owner or agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> mss jssued, I shalq not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> on actor hiring or sub-contracting signature certi lies the following:'I certify the of the performance o work forwhich this <br /> j 'permit is issued shall employ persons subject to workman's compensation laws of�California.' <br /> I will rout Inspec ion prior to grouting and a fin�rl pectdx <br /> Date: I Q <br /> } Title: <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> h <br /> FO DEPA MENT USE ONLY <br /> I <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: Phase 111 Final Inspection <br /> ( Phase II Grout Inspection Date <br /> Inspection By <br /> Date Inspection By <br /> PER SITE El EACH ❑ January 1 &Received By January 31 [I July 1 &Received By July <br /> Fee Is Due: ❑ ANNUALLY . ❑ PER UNIT REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> t PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> OTHER <br /> �. --11 (_-_y9 ? <br /> Date Receipt No. Permit No. ance Date Mailed Delivered <br /> Received byL HEALTH PERMITISERVICES 1601 E.HAZELTP.O:jON AVE.,AYE., Box 2U09 STO-CYTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENT - <br />