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Apprrcatlons war Ise rrocfssea wnen tsuornrttea Vropeny uompletea.we%lure so ailgn t no npPrrcal*ron• <br /> JR OFFICE USE: APPLICAT�aN <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TR! KATE) WATER QUALITY <br /> Application is hereby made.to the San Joaquin Local Hbalth District forel permit to Construct and/or install the work.herein described.This application is <br /> made in compliance with San Joaquin Cc typ4tpisnce NoJW2spd the.rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name _ Phone SCS <br /> Address -z � �. City .- <br /> Contractofa NameLicense 113 7 Business Phone l <br /> Contractor's Address Emergency Ph ones <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> rEPLACEMENTE1 <br /> F'WO.RK(CHECK): NEW WELL❑ DEEPEN❑. RECONDITION❑ DESTRUCTIO,N,❑ <br /> HLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION; PUMP REPAIR 13 c <br /> CE TO NEAREST: Septic Tank Sewer Linea Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit 4 _ Other <br /> Property Line Private Domestic Weil Public Domestjc Well <br /> , JM <br /> USE TYPE OF WELL <br /> 92 INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing 4, <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 , Surface:Seal Installed By: <br /> PUMP INSTALCAT'10_ N: Contractor, <br /> .. -4- . Type of M.P. <br /> i � <br /> ;PUMP REPLACEfMiNT- r' ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done ! <br /> DESTRUCTION OF W4.L: Well Diameter A proximate 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 Iloenaed agent's signature certMes the fgAg.wi Qr"I.certttythatln the performance of the work for whichth is permit <br /> --isdsaped;�t ltfalfnot employ any pb7lE8tn'try such mariver asto become subject to workman's compensation laws of OalArnia." <br /> Contrw s hiring or sub-contracting slgnatu'es cerV11114 the following:"I certify that In the performance of the work for Which this <br /> permit is issued, I.shall erhploy,priions sub( td wP ARI'a_9" <br /> "to n ipWs of California. <br /> 4-wifl->m $go" pftar Ra�rOtltl�'and f 4nsir IftipstRlion. ' <br /> "nod 11L <br /> (Draw Plot Plan-On Reverse Side) <br /> FOR OEPAFJTMENT USE ONLY <br /> PHASE <br /> Application Accepted I3y" Date <br /> Additional Comments: <br /> Phase It Grout 1n iWition, �Ph as Mal Inspection <br /> Inspection By Date `tih�' �i� ...,.T Inspection 6 ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE E } ❑ January 1 6 Received By January 31 ❑ July t&Received By July 71 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE. CHECKtO <br /> DATE DATE , REMITTED z AMOUNT <br /> liz— <br /> FEE , w <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ved by 'Date Receipt No. mit No. Issuance Date Mailed Delivered <br /> P hurt.-.nsmnN ALL COPITS Ttr. INVIIA016MEWAl'RE11Girt'I NIA aniCEi- 1401[.HAWLTON AVE..P.O.002 110119 670C970%CA 10201 <br />