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I <br /> Applications Will Be Processed Whell SaDmPPLICA!Tly ION Completed.Be Sure T-1 ign The APPlicallon. <br /> 60R4rR(ACE-USE. <br /> __ (;nr Non-Trfnslerable.Revocable,Suspendabie) pUpAp&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> t <br /> Application is hereby male 10 the San Joaquin Local Healtl District for a permit to con5lrucl.nnd�or in5lall Ina work herein describetl.This application la <br /> made incompliance with San Joaquin County Ordinance N,pg. 662 a/n/d the rules n0 r uln ionl}f)e S;n Joa coal Health D stric. <br /> Exact <br /> Sire Address_13lL•Ilf�� 'Ke'°'UL /�* (( <br /> Phone <br /> Owner's Name _-.__ �- yr-(� CitysI <br /> N-drrrr�f� Cifinn . x900 3 �b <br /> Atldress -----[-8 Lice se N Business Pho e <br /> Contractor's Name _.�yosQ�JQ �ergency Phone __ .�'S"�o1 Y/ _ -."- <br /> Contractor's Address .3•.'e+�.7- L[ /LTJ X No ,J <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? DESTRUCT Yes .- <br /> TYPE OF WORK(CHECK): NEW WIi DEEPEN O RECONDITION O ` <br /> WELL CHLORINATION 13 WELL ABANDONMENT O OTHER U PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENTS _ Pit Privy --- <br /> DISTANCE TO NEAREST: Septic Tank -�5� _.- Be,, LinR�sspoot/Seepage Pit -------- - Other_-- 4•,- <br /> Sewage Disposal Field__�. — <br /> Property Line_--Private Domestic Well--- Public Domestic Well-_-_- -.- <br /> TYPE OF WELL rr -- <br /> INTENDED USE Dia.of Well Excavation <br /> C3I[�jDUSTRIAL 0 CABLE TOOL <br /> r�/r ❑ DRILLED Dia.of Well Casing <br /> q/UOMESTIC/PRIVATE g <br /> Gauge of Casing <br /> ❑ DRIVEN <br /> ❑ DOMESTIC/PUBLIC RAVEL PACK Depth of Grout Seal <br /> _ <br /> IRRIGATION ROTARY Type of.',rout ._. <br /> 0 <br /> CATHODIC PROTECTION Other information <br /> ❑ DISPOSAL O OTHER _-__--- <br /> Surface Seel Installed BY: <' <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: H.P.— <br /> TypeofPumP <br /> — <br /> PUMP REPLACEMENT: <br /> CI State Work Done- ---- - <br /> ❑ Stale Work Done <br /> Approximate Depth ----- � <br /> PUMP REPAIR: Well Diameter <br /> DESTRUCTION OF WELL: ---- <br /> Describe Materiel and Procedure--------- __ ___--_ <br /> I hereb l comity that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances.stale Inws•and rules and regulations or the San Joaquin Local Health District. <br /> rk for which this perm,t <br /> le,the <br /> y that <br /> Califor <br /> H�ssued^esha Knot employ any persture on in such mannerastogbecomefsubjed to workman's coin the Performance mpensation ethe �the wor of rwhich this - <br /> Contraclorshlringorsub-eontra:ting signature certllies the lollovdng: 'certify that in the performance of the work forwhlch this <br /> permit is issued,I shall employ persons subject to worHman's compensation laws of California." <br /> I wll call for a Gout'rta on Pnor I grouting and a I el�In/�r�lCy7lon,/ �r--- Dolc <br /> _ Titvt:6(�r_L <br /> Signed X - ( raw Plot Plan on Reverse Slos <br /> gp W r7- - FOR DEPARTMENT USE ONLY�*Arq Q r Fps. PE,QrrlrSS�i+'^ <br /> js ,.0 E.C< P AntiT 1"9 1 e TBf.BCow ui.rrF <br /> v vT Date I�--�� <br /> PHA ---_ <br /> Application Accepted By- <br /> Additional Comments: Phase til Final Inspection <br /> pIhIsee 11 Grout Inspection �eInspection By Date_- <br /> Inapection Byjj751=s----- Date-J40412--9 --- <br /> (� _ REMIT <br /> Fee if Due:❑ ANNUALLY ❑PEP UNIT ❑ PER SITE ❑ EACH-REMI❑TTANCEY i A Pecan!BY JanVery aIAMOLOT UUEJuly f 8 Re[aCMEMI. ]I <br /> BILLING GATE REMITTED AMOUNT <br /> LBASE E%PLANATION DATE ---- <br /> FEE <br /> LESS -- <br /> PRORATION <br /> PLUS <br /> PENALTY _.-- ----- I — <br /> OTHER ----- <br /> OTHER ----.s--. <br /> R"'Cl IH ILT b MallEe DOCITO <br /> �aNT'-- tEet[.NAZILTOM AVe..P.O.ser EYDa aTOCRTOM.CA oSMt <br /> R�a <br /> _ APPLICANT-RLTUMN ALL 000126TO" ENVIRONMENTAL HEALTH PERMITIf[PwCEf e <br />