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.� . <br /> Applications Will Be Pr need When Submitted Properly complello.tae duty,f u u W,. .,..,, <br /> FOR OFFICE USE: /'_ !� APPLICATION 22 J ��i . - <br /> w (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT � <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) 41 <br /> Appl iafiCm`is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is. <br /> made In compliance with San Joaquin Cbuny Ordinanc No.1862 and the r les ang regulations of the San Joan Health District. <br /> Exact Site Address (o Ya City/Town <br /> 40wner's Name- Phone <br /> vJf CityAddress Z:2 <br /> . � d'C <br /> Contractor's Nam P License s �jJa 7 S'd B amass Phone �'+ 7L 7 6 <br /> Contractor's Address - Emergency Phone <br /> ( Is Certificate of Workman's Compensation Insurance on FillWith SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 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 /> F 11INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> l [5 DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> 11DOMESTIC/PUBLIC 13DRIVEN Gauge of Casing <br /> I <br /> C1 IRRIGATION ❑ GRAVEL PACK Dep[h of Grout Seal <br /> f1 ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 1 ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - '- Surface Seal Inst Iled By: <br /> PUMP INSTALLATION: Contractor H P <br /> .Type of Pump S7`� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> 1 ❑ State Work Done - - <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materiel and Procedure <br /> s <br /> F - <br /> t 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 /> the performance of the work for which thispermlt <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certllles the following:"I certify that in the performance of the work for which this <br /> j permit is issued, I shall employ persons subject to workman s compensation laws of California." <br /> 1)F 1 will call for a Grout Inspection pdo F <br /> u d a final inspection C <br /> < 4-, e: Date:' <br /> Signed X - - <br /> Draw Plat P on Rdverse Side) <br /> FORD ARTMENT SE ONLY <br /> PHASE 1 Date <br /> Application Accepted By _ <br /> Additional-Comments: s, pp ha III al Inspection _ <br /> 1 Phase II Grout Inspection A 9^�0 <br /> Inspection By 1 <br /> 'Dale Inspection By I Date <br /> Fee Is Due,❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 s Received By January 31 ❑ July t s Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNTOUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> _ vs <br /> 1 FEE <br /> LESS <br /> ! PRORATION. ^ <br /> r PLUS <br /> PENALTY <br /> r a <br /> OTHER <br /> r <br /> OTHER d <br /> : Ort — _ -9 7 <br /> r � � a✓• ���{ Issuance Date Mailed Delivered <br /> Date w R Permit No- <br /> _. Rereived try - •V/—/N i}°.�/ U.S'. uusl inx AVE_P.O.aoa 21109 BTOCKTON.CA 952111 — <br />