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I <br /> LApplications w;n tie rrocessea wnen Suomltled rroperly t:ompleted. tie Sure f o Sign I he Application. <br /> F FCR OFFICE USE: APPLICATION <br /> or Non-Transferable, Revocable, Suspendable) <br /> L I----- --- --- ENVIRONMENTAL HEALTH PERMIT PUPolP&V"=-LL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Iicatlon is her ' vradeto the San Joaquin Local Health Districtfora permittoconstrictand;crinsta IthewcrK herein described This application is <br /> Le in cruwphan with San Jcja--uin County Ordinance�N not a,d the roves e res aro reguia,ions of the San Joaqu,- Leval H_altn Dlscnct <br /> E-act Site Address _Z_2S� .. . / Cel�1L� City;TON <br /> Owner's Name _9yCgAl ES — _ Phone <br /> ` Address 16 fe/,C ���-1!l_Cr city <br /> Contractor's Name _ JVAL _ License # Business Phone <br /> Contractor's Address 2/,3 -���- Emergency Phone _ <br /> LIs Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL C DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ LL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> LLREPLACEMENT❑ / I <br /> DISTANCE TO NEAREST: Septic Tank S� -E Sewer Lines J(iz�_ Pit Privy <br /> Sewage Disposal Field -- - Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well ysD�t Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia.of Well Excavation_el <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing /1 <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: 16"1.VE/t f <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump_ H.P. _a <br /> "PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ Stale 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. <br /> 6' Home owner or licensed agent's signature certifies the following:"I certify that in the performanceof thework 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 /> Contractors 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 employ perspns subject to workman's compensation laws of California." <br /> I will call for a7Gr In echo �r to grouting and a final inspection. <br /> Signed X -� Title: 44;ZCAy Dale: y,S /, /1z zc.Z <br /> (Draw Plot Plan on Reversojide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By Date 3/S/Ba <br /> Additional Comments:_ -- <br /> Phase 11 Grout Inspection �h III Final Inspection! <br /> Inspection By —______.—_ Date Inspgction By- a Date —"sem Juf—YVIT'1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 & Received By July 71 <br /> � KILLING REMITTANCE s REMIT <br /> a. BASE EXPLANATION —� AMCUNi DUE CHECKED <br /> DATE <br /> DATE REMITTED AMOUNT <br /> FEE <br /> LES <br /> — <br /> PRORATICN <br /> PLUS <br /> PLUS I — <br /> PENALTY <br /> OTHER <br /> OTHER -- <br />