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.� Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For�-- Non-Transferable, Revocable, Stispendabie) l 'UMP&KNELL <br /> -- ENVIRONMENTAL HEALTH PERMIT <br /> ...;.OMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. chis application is <br /> ,jade in compliance w4b San.I^aquin County 0 dinance.No.,1862 and the rules and regulations of the San ,Joaquin Local Health District. ? <br /> xact Site Address.-84244 � Se �'7zCr'y 3 City/Town^ �C �-- _.___ _ W <br /> Owner's Name )-- --- Phone <br /> 'lddress X3/.2 d�� S� s — City 'ZJ=a t->e I <br /> ontractor's Name '-a-"`-i -_ icense a3B#fytz/ Business Phone ,�.cN� <br /> �Gtontractor's Address �_�_ Emergency PhoneTA—��7rQ U <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes __._ No --� <br /> YPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> -ELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> -ISTANCE 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 f� <br /> I INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation _- <br /> "PJ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing _ All <br /> '7 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> 1 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER .. Other Information <br /> GEOPHYSICAL Surface Seal Installed By: <br /> 'UMP INSTALLATION: Contractor <br /> Type of Pump_. H.P. <br /> PUMP REPLACEMENT: State Work DoneA,po�c C�� &2,5%_T� ? <br /> SUMP REPAIR: ❑ State Work Done' _ —. - --1 <br /> —.)ESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> a 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 rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature 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 /> Contractor's hiring or sub-contracting signature certifies the following:"I 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 /> I will 11 for a Grout Inspection prior to grouting and a final Inspection. <br /> -•Signed X ___ Title: _ jnGG _ Date: a� <br /> ,/, �t "Ve` a� �`��� �L (DrPlot Plan1 OCA o Reverse Side)/ <br /> /(/O/ KFO EPARTMENT USE ONLY <br /> e-�� <br /> [fi . <br /> 1 PHASE I z DIC3f/ <br /> 11 Application Accepted By Date <br /> Additional Comments: - <br /> Phase II Grout Inspection "e III F1 11n ection <br /> Inspection By Date__ Inspection B ��.e� / Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januaryl�❑ July 1 &Recelved By July 31 <br /> _ REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> LESS ` <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -- <br /> Received by Date Recelpt No. Permit No. ssu nce Date Mailed Deli y d r <br />