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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The ApPllcatlon. <br /> FOR FtCE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL / <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 'OMPLETE IN TRIPLICATE) WATER QUALITY <br /> �pplicatton 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 wjtf],�9(�o lipre tY i��e Z and the rules and regulations of the <br /> wi San J q}.pga District <br /> Exact Site Address ` i S(�'b S ![�ff`A�7,{c City/Town <br /> /IV <br /> Owner s Name Phone <br /> Address rf l _ City <br /> License K D f Busi J?none <br /> Contractor's Name �j <br /> Contractors Addr Emergency Phone .� <br /> Is Certificate of Workman's Compensation insure on Fit h SJLFID? Yes No <br /> TYPE OF WORK(CHECK): NEIN WELLEEEPEN 0 RECONDITION❑ DESTRUCTIONS <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> REPLACEMENTS t <br /> �/�/ I C <br /> DISTANCE TO NEAREST: Septic Tank+--. Sewer Lines Pit Privy <br /> Sewage Disposal A�F/ieCesspool/Seepage Pit Other <br /> property Linflf�!Private Domestic Well Public Domestic Well �r <br /> INTENDED USE TYPE OF WELL /Q X:; ZZ <br /> l USTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> DOMESTIC/PRIVATE 0 DRILLED Dia.of Well Casing ' <br /> ❑ DOMESTIC/PUBLIC ❑ D Gauge of Casing - <br /> ❑ IRRIGATION AVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout ��I4�aa�r1Q� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I] GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ^'- <br /> PUMP REPLACEMENT: 0 State Work Done V1 <br /> DUMP REPAIR: ❑ State Work Done <br /> )ESTRUCTION 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 ru le5 and regulations of the San Joaquin Local Health District. P <br /> Home owner or licensed agent's signature certifies the loll"Ing:"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.' <br /> Contractor's hiring or sub-contracting signature certifies the following. 1 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." <br /> 1 Will cen forp Grout inspection Prier to grouting and a final inspection. <br /> signed X Tmen ruAln Dale: <br /> (Draw Pbf Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1r` Oate Q <br /> Application Accepted By <br /> Additional Comments: 111 Final Inspection <br /> 11 Grout InspectionDa �,_ Date\Cr79 :V <br /> Inspection By�— Date \n--aL-S� Inspection By --•�r— <br /> Fee is Due: O .WNUAuv ❑VER UNIT ❑ PER SITE ❑EACH 13 Jamiary I a Racened By JwI 31 O July t i ReII By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNT DUE CHECKEO <br /> DATE DATE REMITT® AMOUNT <br /> FEE <br /> Mae <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> by pN@ rIEG. t NV. ParmA N0. , Mlww o.11.«.e <br /> HA=ELTON AVG,P.D.M> grocKTOM.CA PMIr <br /> AICANT—ttMM AIM COP" ENwRO sse"TAL NEM.IN EE1Yfr/aE1Wi(Za <br /> feel-R. <br /> PPL <br />