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Applications Will Be Processed When Submitted Properly Complete u(�„ I igATWe AWlic��i�r�. <br /> FOR OFFIOE USE:, APPLICATION t� <br /> {For Non-Transferable, Revocable, Sus ble <br /> ) <br /> J ENVIRONMENTAL HEALTH P MIT SSP PUMP wE« <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY flike <br /> iC Application is herebymadetotheSanJoaquinLocalHealihDistrictforapermittoconstructand/oull —TvVOUo ih Ir"Tbed.Thisapplicationis <br /> made in compliance with San JoaquinCounty Ordinance No.1862 and the rules and regulations San Joaquin Local Health District. <br />' Exact Site Address (D 9 s�-, �,r , City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name /.� License# 9 kcf) c Business Phone <br /> Contractor's Address ' G Tc - Emergency Phone t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_41-11 No J <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy ' <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL �7 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A4 t; cfyjk.al�l <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: a-State Work Done <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. �O <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 /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." qqq <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." N\ <br /> I will afll�tor . out Inspection prior to grouting and a final inspect! <br /> Signed X ,7 - �Gc-� Title: Date: (� / d' ,1 <br /> � <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I q)/ <br /> Application Accepted By to Date �f <br /> Additional Comments: <br /> Phase II Grout Inspection se II Final Inspection /0- <br /> Inspection By Date Inspection By e <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SfTE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - ate Receipt No. Permit No. Issuance Date Mailed elivered <br /> 4_ APPLICANT—RETURN ALL COPIES TO: ENVIRONMFNTAL HEALTH PERMIT/SERVICES..' -x..:1601.E.HA7;• ^y AVF -- <br />