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- 'cations WIII Re Proces~se '.When SugPPLICAT{ON <br /> L�F,�,ICE USE: (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITYrk application is <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe San Joaquin Local alehNost1862 and pthe rules and regulatioons of he San Joaquinln described- <br /> Health District. <br /> made in compliance with San Joaquin County Order Glty/Town �� <br /> Exact Site Address .� <br /> Phone <br /> ---�yyQ Ortt sc�em �? _�` �-•---? <br /> - G V.6Owner's Name <br /> City— C7 <br /> Business Phone <br /> Address License# <br /> Contractor's Name f;&,I [ , <br /> _ Emergency Phone _ <br /> Contractor's AddressNo C <br /> is Certificate of Workman's Compensation insurance, File Wit It RECO <br /> 7 Yes STRUCTION❑ <br /> WORK (CHECK):TYPE OF CK): NEW WELL❑ DEEPEN 11RECONDITION <br /> 13WELL CHLORINATION 13[I WELL ABANDONMENT ❑ OTHER 11 PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ Sewer Lines I Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank __ Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well — <br /> ` Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> r Dia. of Well Excavation <br /> 13 CABLE TOOL <br /> ❑ INDUSTRIAL 1-1 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing - <br /> ❑ D G/PUBLIC IJ-GRAVEL PACK Depth of Grout Seat <br /> ® IRRIGATION ❑ ROTARY Type of Grout <br /> r ❑ CATHODIC PROTECTION Other Information <br /> f ❑ DISPOSAL 11 OTHER .�— <br /> Surface Seal Installed By: � <br /> ElGEOPHYSICAL <br /> PUMP INSTALLATION: Contractor__— _ H P <br /> Type of Pump <br /> ❑ State Work Done L011111 — <br /> PUMP REPLACEMENT: <br /> PUMP REPAIR: State Work Done Approximate Depth - <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe'Material and Procedure -- <br /> I licatiO and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that 1 have prepared this app <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. <br /> or which this permit <br /> foloin :"I certiy that in the performance of the work f <br /> Home owner or licensed <br /> agent' signatunen ls t gbecomef subject to workman's compensation flaws of Ca{forn a." <br /> is issued, I shall notemploy Y such mannera <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ( I w 1 call for a Grout Inspec to rio to g and final inspection. <br /> � ����� i/ �j _ !I ilia: :.��— Date: <br /> Signed �s r (Draw Plo Ian on Reverse Side) <br /> OR PARTM T USE ONLY <br /> I- <br /> PHASE t Date -- <br /> Application Accepted By <br /> -- <br /> Additional Comments:— Phase III Final inspection <br /> - Phase N Grout Inspection J Inspection By Date <br /> inspection By — Date <br /> REMIT <br /> Fee 15 Due: ANNUALLY ❑ PER UNIT 'PER 547E C1 EACH El January I &Received By January 31 July 1 8 Received 8y July 3t <br /> 1 BILLING REMITTANCE I -S . AMOUNT DUE CHECKED <br /> BASE EXPLANATION DAT DATE REMITTED AMOUNT <br /> I <br /> U <br /> FEE !1 <br /> LESS ll �/ <br /> PRORATION <br /> PLUS fj{I <br /> PENALTY L <br /> OTHER iLLLI <br /> OTHER I <br /> Received by Date Receipt o. <br /> Perrnit No. Issuance Date Mailed Delivered <br /> N <br /> MIT/SERVICES E.HAZELTON AVE,APPLICANT—RETURN ALL•COPIES TO: 'ENVIRONMENTAL HEALTH PER <br /> 1501 . P.O.Box 2409 STOCKTON,CA 9520 — <br />