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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> PUMP&WELL <br /> 0"` ENVIRONMENTAL HEALTH PERMIT <br /> COMPLETE: IN TRIPLICATE W TER ,UnALITY <br /> Application is hereby made to the San Joaquin Local Health District for a ttt000nstructand/or install the work herein described.This application is <br /> made in compliance, *th an Joaquin C my Or inance No.1862 and the ru es an regulations of the San Joaquin oval Health District, <br /> Exact Site Address I� i./�n.v ��� y����f h y�nLe�City/Town Sr_ 4"v <br /> Owner's Name I1LCrtrr //Gl w k44 Phone ef k - .Z <br /> Address City <br /> Contractor's Name p9mrn. 0,,gLicense#,?,T,7 y Business Phone /D <br /> Contractor's Address z i Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes k No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN El RECONDITION❑ DESTRUCTION❑ r „ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ V , <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines_Z! 6 -f Pit Privy - <br /> Sewage Disposal Field /1�0 t-f _ Cesspool/Seepage Pit ether <br /> Property Line_ Private Domestic Welit 50 14 Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> it <br /> ❑ INDUSTRIAL A CABLE TOOL Dia. of Well Excavation / <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> [XIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Q <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 4tdNE/t <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done F <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared 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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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." 1 <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 pers s subject to workman's compensation laws of California." <br /> I will c I for a Gr t I ecti p or to grouting and a final inspection. t� <br /> Signed X Title: __-- 14 AI Date: Z J /Yey <br /> (Draw Plot Plan on Reverse de) <br /> . r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE NtAU&_ �� r (� <br /> Application Accepted By ©�✓ Date ` Sit <br /> r <br /> Additional Comments: <br /> Phase II Grout Inspection ase 111 Final In pectic <br /> Inspection By Date Inspection B Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ AMOUNTt7UE Cf <br /> DATE DATE REMITTED H <br /> AMOECUNTKED <br /> � <br /> FEE tt <br /> LESS — r <br /> PRORATION f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 7: <br /> Received by Date Receipt No. Permit No. WuanceIDate Mailed D livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 KTON,CA 95201 <br /> IL <br />