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FOR OFFICE USE: . AF'F'LIGA1 iV1V n <br /> (For Non-Transferable, Revocable,Suspendable) <br /> _ � PUMP&WELL j <br /> ENVIRONMENTAL HEALTH PERMIT i <br /> =t � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY- <br /> ! <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install theworkherein described.This applicationis <br /> made in compliance with San Joaquin County Ordinance No.'1862 and the rul Ind re u a 'o s e San Joa inn Local Health District. <br /> Exact Site Address Zr I ICE. 4� a " C I y/Town <br /> i <br /> Owner's Name4�IMINE Phone <br /> Address - 1 C.. :, City _ <br /> 'jp1 CN R License#�P ' Business Phone &44 L'!'�� _ <br /> Contractor's Name M <br /> Contractor's Address CL i EV lu C* Emergency Phone <br /> is Certificate of Workman's Compensation Insuranc File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN10 T`" ` RECONDITION❑ JDESTRUCTlON❑ *. <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ® :-OTHER r❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ } 7_77 1'r <br /> �a .Ij <br /> Sewer Lines �' Pit Privy <br /> DISTANCE=TO NEAREST: Septic Tank �... <br /> Sewage Disposal Field r" Cesspool/Seepage Pit Other- <br /> Property Line �Private Domestic Well rte" Public Domestic Well <br /> ' INTENDED USE TYPE OF WELL �I <br /> i ❑ CABLE TOOL' Dia. of Well Excavation Q <br /> ❑ {ND AL _ -� 4- <br /> _LV' O_MESTIC/PRIVTE• ❑ DRILLED r � Dia;'vf`Well Casing <br /> �.Yy�•..c: _......_ 'a_" '._.. -•-:.e.ryn..:.e.,..n-..Y:-!rl"eb°�y.�.r..�r��w'.^ - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing F <br /> 11 IRRIGATION € 13GR ACK Depth of Grout Seal <br /> ❑ CAlO,DIG,PROTECTION r OTARY ;.':F a :`" " ype of gout p\l <br />( <br /> J3.-DISPOSAL 11OTHER Other Information <br /> •." <br /> +�' Surface Seal Installed 8y: <br /> ❑ . <br /> .GEOPHYSICAL <br /> pUWF INSTALLATION: Contractor <br /> 1 i ' <br /> H.P. <br /> Type of Pump <br /> i ` <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> t 13 State Work Done <br /> PUMP REPAIR: i <br /> DESTRUCTION OF WELL: i Well Diameter Approximate Depth <br /> kk # Describe Material and Procedure <br /> l F <br /> I hereby cer#ify that I.have prepared this application and that the work will be done in accordance with San Joaquin County Y <br /> �. ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <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 /> v <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ' <br /> , <br /> t following:"I certify that in the performance of the work forwhich this <br /> Contractor's hiring orsub-contracting signature certifies the <br /> pe t is issued, I s all employ pe ons subject to workman's compensation laws of California." <br /> I w all for a Gra pect' ri r to g uting and a final insp�tion. <br /> Signed X <br /> Title. <br /> ._a_, � Date'- <br /> Signed <br /> ate: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I t Q Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phas 1 ' l Inspection <br /> I ( Date_ Inspection By Date <br /> Inspection By t <br /> �? <br /> Fee Is Due: ❑ ANN ALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Jul 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE' CHECKED! <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT-S <br /> FEE <br /> -I&J?_ <br /> LESS } <br /> t PRORATION ' <br /> PLUS . <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .,,t:.- _ acs_.•_�-- _. � — .• _ ,. Is Mailed. Delivere��� � *a <br />