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Applications Will Be Pr Basad When Submitted Properly Complerea.oe.Puiq ,o <br /> t •..;kr••,�-••r;- <br /> FOR OFFICE USE, lo,L APPLICATION - _`. •.f . - <br /> u (For Non-Transferable, Revocable,Suspendable) F L <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) a <br /> WATER QUALITY <br /> A plii:dti ilsherebymade to the San Joaquin Local Health District fora permit to construct and/orinstall the <br /> work herein described.This application Ie <br /> made In compliance with San Joaquin Cbunty Ordina c No.1862 and the r I s en regulations of the San Joan al Heatlh District. �- S <br /> Exact Site Address 6 � -v, City/Town <br /> I <br /> Phone <br /> :Owners Name �- - <br /> n vtOYl : <br /> Address 6y —•7L7 6 <br /> Contractor's Nam License p /fj 214 Business Phone <br /> Contractor's Address Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on Fi With <br /> SJLHD7 Yes�— No <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN 0 RECONDITION❑ DESTRUCTION 13 <br /> WELL CHLORINATION 0 WELL ABANDONMENT❑ OTHER 11 PUMP INSTALLATIONT-3 PUMP REPAIRS .` <br /> REPLACEMENT❑ (i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy -1 <br /> Sewage Disposal Field - Cesspool/Seepage Pit Other <br /> Public Domestic Well <br /> Properly line Private Domestic Well �x <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL <br /> 0 CABLE TOOL Die.of Well Excavation s . <br /> W DOMESTIC/PRIVATE 0 DRILLED Dia.of Well Casing <br /> 0 DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing , <br /> 0 IRRIGATION 0 GRAVEL PACK Depth of Grout Seal s <br /> 0 CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> 13 DISPOSAL 0 OTHER Other Information <br /> 0 GEOPHYSICAL - Surface Seal Inst it ad By, <br /> A <br /> PUMP INSTALLATION: Contractor H P 7 <br /> ,Type of Pump <br /> PUMP REPLACEMENT: �0 State Work Done Q <br /> 1 0 State Work Done < <br /> 1 PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> s , <br /> j I hereby certify that I have p epared this application and that the work will be done In accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. le_ <br /> Home owner or licensed agent's signature certifies the following:-I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contnactor's hiring or sub-Contrasting signature Cartllleathe following:"I certify that in the performance of the work for which this 4r, '-t. <br /> permit is issued. I shall employ persons subject to workman's compensation laws Of California." ` <br /> 1 will Call for a Grout Inspection pdo o u rrg'a d a Tinel inspection. <br /> ..,� �. e: 4/O•/ Date:.. <br /> Signed X - <br /> (Draw Plot P on Reverse Side) <br /> t <br /> FOR DE <br /> PARTMENTIUSE ONLY - <br /> PHASE 1 Date�. <br /> 1 Application Accepted BY <br /> Additional Comments: a RI al insDate <br /> pection / <br /> 1 Phase 11 Grout Inepedllon <br /> Inspection BY Date Inspection By h <br /> E : f <br /> Fee Is Dile:0 ANNUALLY 0 PER UNIT PER SITE ❑ EACH E3REMIT <br /> JarMary 1 a ReeaNed BY January 31 ❑July t a ReGeiv July 91 <br /> I- BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ✓ BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> t ys ✓ <br /> FEE <br /> LESS <br /> 1 PRORATION. It <br /> I PENALTY fill I <br /> OTHER <br /> r <br /> OTHER d _ • <br /> • 9 � <br /> _ p Pennil NP- IUuenee Date MalleE Delivered <br /> Dale /aap✓Fa/y%i& <br /> AppUCANT—RETURN ALL COPIES , r ENVIROHMENTJICNaALTN PERMIT/BERYICES .INI E.HAZEL��,P'.acv 1009 aTOCKTON,GA 55301 <br />