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i aPbn ,jylltsae r es `.�� Submitted <br /> FOR cd1=FICE use: properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> 98r <br /> J <br /> OCT C gr ransferable, Revocable, Suspendable) <br /> U 1 f O ENVIRONMENTAL HEALTH PERMIT PUMP&WELL / <br /> (COMPLETE IN TRymadeto J�?AQUIN LOCAL WATER QUALITY. <br /> Application is hereby made to h�-• Iz <br /> . <br /> _+�1L� l�ethDistrict for apermit toconstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin C urlty Ordinance No. 1862 and the rules and regulations of the San aqu vocal Health District. <br /> Exact Site Address yr? - <br /> Owner's Name City/Town p� <br /> Address Phone-3& <br /> Contractor's Name 10 City � <br /> Contractor's AddressB <br /> © Licensed f <br /> 1�j1, �o���e . , - --����.� usiness Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? erg Yes <br /> Phone -. v <br /> TYPE OF WORK (CHECK):' NEW WELL❑ esy No <br /> WELL CHLORINATION 11DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ -� <br /> WELL ABANDONMENT ❑ OTHER 11REPLACEMENT❑ PUMP INSTALLATION 11 PUMP REPAIR <br /> DISTANCE TO NEAREST: Septic Tank ane <br /> Sewer Lines <br /> Sewage Disposal Field <br /> � Pit Privy <br /> __ Pro ert 'Line F''1 x—_ Cesspool/Seepage Pit <br /> a Private Domestic Well Other <br /> OUMiNSTALLATION: T <br /> ENDED USE ��' �'P y - _ Public Domestic.Well <br /> TYPE OF WELL --�--- '-`�'"" <br /> STRIAE '❑ CABLE TOOL ESTIC/PRIVATE ❑ DRILLED Dia,of WeIIExcavation <br /> ESTIC/PUBLIC Dia. of Well CasingATION ❑ DRIVENGauge of Casing� ❑ GRAVEL PACK tODIC PROTECTION Depth of Grout Seal <br /> SAL = ❑ ROTARY F Type of Grout <br /> .. ❑ OTHER €,.'HYSICALOther Information <br /> Surface Seal Installed By: <br /> Contractorcype of-Pump <br /> PUMP REPLACEMENT: <br /> El State H P. <br /> PUMP REPAIR: <br /> ! 1/Uork Done <br /> 19State Woric Done <br /> DESTRUCTION OF WELL: k <br /> Well Diameter �' 'fi� it <br /> Describe Materialand Procedure Approximate Depth <br /> 1 hereby certify that I have prepared this application and that the work will be done n a cwith San an Joaquin Co <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. unty f <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit `1 <br /> is issued, I shall not employ an � <br /> p Y y person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following: <br /> permit is issued, I shall employ persons subject to workman's compensation laws aws of California.,,y that in the rmance of the work for which this <br /> I wi !I f a Grout In ection prior to routing and a final inspection. { r <br /> Signed )( .- <br /> :hie: , �' -�'f <br /> {Draw Plot Plan on Revers Side) bate: 13 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 - <br /> Application Accepted By. <br /> - <br /> �- a- s1J <br /> Additional Comments: "'= Date <br /> Phase 11 Grout Inspection <br /> Inspection By <br /> By Date Phas 111 Final Inspedtlon <br /> Inspection B <br /> [, to <br /> Fee IS Due., ❑ ANNUALLY ❑ PER UNIT �January <br /> ❑ PER SITE -0 EACH ❑ Januar 1 &�• y RecBy' 31 ❑ July TB SE g Reee;ved 8y July 31 <br /> ExpLANA'i107+1"" �-+r�----�-.-.fFEMITTANGE�,..�,. $ -� � REMIT <br /> LATE DATE REMITTED AM011NT'Dl1E^�------CHECKED-�-=' <br /> FEE 4 <br /> AMOUNT <br /> LESS <br /> PRDRATION <br /> PLUS 9 <br /> t <br /> PENALTY ' <br /> OTHER ' <br /> OTHER a <br /> ti F <br /> Received by DateRO ' <br /> Receipt No. - -PermR Np.�- <br /> APPLICANT—RETURN ALL COPIES TO: ENYIAONMENTAL HEALTH PERMITPermit CES Issuan a Da a Mailed' - <br /> Delivered <br /> ifidl E.HA2ELTON AVE.,P.O.Box 20w <br />