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Applications Will Be Processed When Submitted Properly CgmPIeeo To-SIP <br /> -s Mr <br /> I-A,W <br /> i aUoo, <br /> FOR OFFICE USE: APPLICATOjlI ] l <br /> (Frr Non-Transferable, Revo J.Spendble) P&WELL <br /> HE" <br /> i <br /> ENVIRONMENTAL HEALI`H PROMT3 J 1981 <br /> COMPLETE IN TRIPLICATE) NATER QUALITY <br /> —Ipplieation is hereby madetothe San Joaquin local Health District fora permit to consGAfl6ndGe1Aslal We WkArein described.This application is <br /> Tade in compliance with San JoTm County Ordina a No. 1862 and the rules and rdg iwtloris'of f@eS21i o�uin Local Health District. <br /> .xact Site AddresssJ pp � 3 3.�' Z oQ-vc-[�®�7 �"�'�- City/TownIV <br /> a <br /> —)wner's Name L4h4.�4 �^ >Y�-o�� Lc/�i.�-( /� Phone <br /> iddress O, d'v-i_ City <br /> :ontractor's Name License#1L 23 73 Business Phone <br /> _:ontractors Address n ::2� r.r� Emergency Phone '^ <br /> 0 <br /> s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No 1 <br /> YPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ 6 <br /> VELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR -� <br /> IEPLACEMENT❑ �( <br /> ASTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage`Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Dompstic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ' <br /> 7 INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> 7 DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> 7 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 7 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> —7 DISPOSAL ❑ OTHER Other information <br /> 7_GEOPHYSICAL - Q Surface Seal Installed By. <br /> cUMP INSTALLATION: Contractor <br /> TYPe of Pump u H.P. ZA,O <br /> SUMP REPLACEMENT:` p State Work Done <br /> SUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL - Well Diameter - - . . . Approxi a Depth <br /> Describe Material and Procedure ' <br /> i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sao Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certitythat 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 /> 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 persons subject to workman's compensation laws of California." <br /> I xriµ"fit a Grou9papection prior t grouting and a Mal ins <br /> Signed X � 1�L6- `y .¢�ritle: Date: <br /> (Draw PioloPlan on Reverse She) <br /> F&R.DEPARTMENT USE ONLY ,cam rT�q <br /> PHASE 1 1 ^ 1(r� (YV\ ,\"., VV'\q�� v, Date <br /> Application Accepted By ���7kkdi\\\\ "\ 1 .Yti+ <br /> Additional Comments: <br /> 11 Grout Inspection a Ill Final Inspection <br /> Inspection By Date Inspection B Date <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jwuary 1 6 Received By January 31 ❑ July 1 8 Received By Jury 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DAVE DATE REMITTED AMOUNT WE CHECKED AMOUNT <br /> FEE <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY I <br /> OTHER <br /> OWER _ <br /> 2 n n � I-9 t <br />