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1t <br /> App!!eatlors Will*&Wrocessed When Submitted Properly Completed.Re c„r��E <br /> P Y a _ ..,Sign the Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> -- - - --- ENV)RONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WAT:q 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 Orc(inanc-2�po.1862.and the rules and egula!ions of theSan aquin Local Health District. <br /> Exact Site Address��Sr `f_—/� /W--Y--__� �_ City/Town r�J_N_ - <br /> J /o <br /> Owner's Name -J 7j-_CO �_ � t_O..E __ Phone <br /> Address_�-LZ ��_� city�.lv__.�—__-_ _ <br /> Contractor's Name.-� , 1-/.yr_l( ��1 /'a, License q �1/_�_ 3usiness Phoney-. __ <br /> Contractor's Address / �� LLL^—� Emergency Phon <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes— No pCIO <br /> TYPE OF WORK(CHECK): NEW WELL,, DEEPEN❑ RECONOITION❑” DESTRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ (� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �,-( Sewer Lines SO — Pit Privy <br /> Sewage Disposal Field-//.!Q r-t-__Cesspool/Seepage Pit ----y_ Other - <br /> Property Lined'�-}Private Domestic Well YC' ' Public Domestic Well <br /> 1 INTENDED USE TYPE OF WELL <br /> 11INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation__�� <br /> DOMESTIC/PRIVATE ❑ DRILLED" Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 4_4J4.SS l l) p V <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal—__5la <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ Other Information r' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: e­i.,zaA-A- --� <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump _ _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done — <br /> PUMP REPAIR: ❑ State 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 wCl be done in accordance with San Joaquin County <br /> ordinances•state laws,and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's Irignature certifies the following:"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 /> Contractors hiring or sub-contra ting signature certifies the following:"I certify that in the performance of the work forwhich this \ <br /> permit is issue4,I shall emplo/ypersons :object to workman's compensation laws of Cal,fornia." ` <br /> I W#t-c��u/ r GroW I�n{spppeecc n prior to grouting and a final Inspection. <br /> Signed X �� � %t" '- t ---- — Title: �<'"r 1_-- ----------- Date:!_L_f�/) d <br /> (Draw Plot Plan on Rev rse Side) J <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 6\ 1 fin., C yn�. <br /> Applicetion Accepted By/� � a(�-%-"'-�` -- - ---(J�`^�^;d� Cate -' l- <br /> Additional Comments: (}? WC lioA <br /> \yphasQ`11 Grout Inspection _ V Pas 111 Final Inspec <br /> Inspection By— Date ___ Inspection E. Date <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITr ❑ EACH ❑ January 1 d Received By January 31 ❑July 1 3 Recerved By July 31 <br /> _ --- <br /> -.-T. ___ .. ._..,_..._.._._ -.. _. _ __._.r__.--- _...._--__-. _-__. .____..__._ <br /> I BILLING i REMITTANCE I $ AMOUNT DVE CHECKED <br /> REMIT <br /> pASE I F`!P!ANATION DATE DATE I REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> UTHER <br /> . _._ <br /> HeV+^d by- Pru•,p•Nn f 1 N Ix:uan Dale M�,led OeI e d <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL tiEALTH PEPMIT�SERVICES 1601£.HAZELTON AVE..,P.O.eo■2009 STOCKTOM.GA 9520I <br /> I <br />