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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r FOR OFFICE USE: APPLICATION <br /> MP- COM �N (For Non-Transferable, Revocable, Suspendable) <br /> 3 PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE L--�� ,!S§ ,8E:C—V o)WATER QUALITY Qct 3 —I�-0� <br /> Application is hereby madeto the San Joaquin Local HealthDls- tTicifor a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordi ance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exacts Site Address 6t -®� L U.As S#ft" ^ �ar).N Jr la�arAieJ�roo✓ City/Town �aes.a� o 112 1✓deA�ri, <br /> -7 V-�' <br /> Owner's Name 11 <br /> __ Phone - <br /> Address 'S /.I ��--��///✓" •� '' p'' City <br /> Contractor's Name S�_,�bk)t i C License ff ! -7 �Business Phone 046Y W7 <br /> Contractor's Addres Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on Fie With SJLHD9 Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> �- WELL CHLORINATION ❑ WELL ABANDONMENT OTHER ❑' PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ r ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines . Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> { ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing _ - <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 54 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type Of Grout <br /> ❑ DrSPOSAL - ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: - Contractor s�e.AO` .rw�i1 <br /> Type of Pump ;r-z,✓X H.P.- e46 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> I PUMP REPAIR:, State Work Done <br /> T <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> i Describe Material and Procedure <br /> r <br /> j� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County '.,. <br /> t i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Horde owner or licensed agent's signature certifies the followirl certify that in the performance of the work for which this permit <br /> 1. 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 orsub-contracting signature certifies the following:"I certify that in the performance of thework forwhichthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> ( 1w I call for aGrout <br /> -In�sp to prio o g ting an final inspection. q / <br /> Signed >�' ,,d„ � 'ue: .�l ng.i` Date: <br /> ® U (Draw Plot Ian on Reverse Side) <br /> E <br /> .. FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By \ Date <br /> .' Additional Comments: • _ <br /> I M <br /> EPhase II Grout Inspection Phase 111 Final Inspection .+ <br /> If` <br /> 'I Inspection By Date Inspection Bye'+'(. '201 -- Date <br /> I , Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '❑ EACH ❑'January 1 &Received By January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DAT REMITTED AMOUNT DUE CHECKED <br /> B <br /> P AMOUNT <br /> i FEE <br /> r <br /> LESS <br /> PRORATION <br /> I PLUS <br /> PENALTY <br /> It OTHER I ' <br /> d _ <br /> d OTHER <br /> ,� Received by Date. Recelpt No. Permit No. Issuance Data Mailed Delivered <br />