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n�CE <br /> plications Will Be Processed When SubmittedPropenyAPPLICATION <br /> it., (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> ere(COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health Dostr$cSt2 and prie rules and re ula ions of thlthe work he S n Jo quinln tical Healdtri Dist-This rict. Is <br /> made in compliance with San JoaquinCounty 9rdina�ncre NCity/Town S <br /> Exact Site Address Phone <br /> Owner's Name <br /> Address ' <br /> License# /9��? -- Business Phone <br /> Contractor's Name Emergency Phone Cp <br /> Contractor's Address _ Yes�f No <br /> Is Certificate of Workman's Compensation IEl DEEPEN❑ RECONDITION❑ DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field l <br /> Property Line Private Domestic Well Public Domestic Well <br /> TYPE OF WELL <br /> INTENDED USE Dia. of Well Excavation <br /> C3 INDUSTRIAL ❑ CABLE TOOL <br /> C3 DRILLED _ „w Dia. of Well Casing <br /> O. DOMESTIC/PRIVATE ❑ DRIVEN Gauge of.pasing <br /> ❑ DOMESTIC/PUBLIC DeptY1 of'Grout Seal <br /> C3kRRIGATION ❑ GRAVEL PACK +, <br /> ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surtace Seal Installed By. <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: <br /> Contractor H P <br /> Type of Pump <br /> State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL Well Diameter f� <br /> � Describe Material and'Procedure <br /> t that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify <br /> r ordinances, state laws, and rules and regulations of the San Joaquin Local F1nLth District. <br /> gfollowing: y that i <br /> Home owner or licensed agent's signature <br /> stonen such mannerasto become subject to workmanas compensationnce of the work laws of California,"it rr <br /> ` is issued, i shall not employ any p C� <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work#orwriich this <br /> ect to workman's compensation laws of California. <br /> permit is issued, I snail employ,persons subj <br /> ' °li <br /> no and. incl i -pection. <br /> 1 w'11 call for a Grout Inspect on rri gr <br /> Dake: <br /> itle: <br /> Signed ][`- / (Draw Plot n on Reverse Side) <br /> E <br /> FOR DEPARTMENT USE ONLY <br /> �o'� � O� Date �` 9-42-0 <br /> i- PHASE I �"�`-'. �\qL, _ <br /> fApplication Accepted By <br /> Additional Comments'. p <br /> h;ap 11 nal Inspecttan <br /> i. Phase It Grout Inspection " Date <br /> Date Inspection By <br /> inspection lay : <br /> ❑ January 1 &Received By January 31 ❑ July 1 B Received By July 31 <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH REMITTANCE l5 AMOUNT DUE CHECKED <br /> BILLING DATE REMITTED AMOUNT <br /> r BASE EXPLANATION DATE <br /> CIO <br /> FEE <br /> r � <br /> i" LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER j <br /> OTHER <br /> Receipt Nv. Permit No. <br /> tss ante ate Mailed Delivered <br /> Received by Date 1601 E.HAZELTON AVE.,P.O.Box 2069 STOCK70N,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERViCES <br />