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L ,.rr,...a.....,. o,..... �,....�»... ..,.�,, ,,,,,,,,,,,,�.. �,..r�„r w„,r,c.oa. ..o �..,� ,�„y., .r.�,•rw,..a..,r. <br /> FOR r3FFICE USE: APPLICATION <br /> r <br /> (For Non-Transferable, Revocable, Suspendabic <br /> PUMP 1,WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> r <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application 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 County Ordinance No 1862 and the rules and regulations of the Sag-Joaquin Local Health District. <br /> Exact Site Address ?� Mfr 0 O G n'L,(�..T-0 R n • City/Town <br /> Owner's Name d dlwr 67s 6 1-11 ,_ Phone <br /> Address aya�.s ©� o w/G C City @ <br /> Contractor's Name y� aa tleLyn RQ/1- /�i hse J�7� Business Phone 7— 24— <br /> Contractor's Address l.Oip TT a LWT IFrgency Phone �T'h <br /> Is Certificate of Workman's Compensation Innssyrance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELLJS DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION,{ PUMP REPAIR❑ <br /> REPLACEMENT❑ _* y, <br /> DISTANCE TO NEAREST: Septic Tank —4 f/ Sewer Lines 4 ! Pit Privy 40 IL `�. <br /> Sewage Disposal Field S� f' Cesspool/Seepage Pit Al A�­ pt� A- <br /> Property Line��_ Private Domestic Well Public Domestic Well N <br /> INTENDED USE TYPE OF WELL <br /> ` ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation AQ •4XS <br /> DOMESTIC/PRIVATE r❑ DRILLED Dia. of Well Casing <br /> W❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing — QyG <br /> .. ❑ IRRIGATION Rr GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION RrROTARY Type of Grout vpt't 4W- /7” <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ` ❑ GEOPHYSICAL Surface Seal Installed By: IVYRa C ry n <br /> PUMP INSTALLATION: ContractorLG��f�.J d 't'y'► -(f <br /> Type of Pump✓I}S k H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ` PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth s� <br /> Describe Material and Procedure �7 <br /> r <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:' <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 amp persons subject to work an's compensation laws of California.” <br /> I will I for a Gr Ins Ion or touting a d final inspec <br /> Signed X Title: Date: If <br /> (Draw Plot Plan on Reverse Side) <br /> ` FOR D PARTME USE ONLY <br /> PHASEI <br /> Application Accepted By Date <br /> yr Additional Comments: <br /> Phase If Grout Inspection G Phaa;yolll Final recti nn <br /> Inspection By V�1--. � Date`s i1� ) Inspection By ate T <br /> ` Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Receival By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE E AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> bw FEE O Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> ho PENALTY <br /> OTHER <br /> LOTHER <br /> _7-7 I-q e <br />