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Applications WIII 130 Processed When Submilled Properly Completed.Bo Sure TO Sign Tho Application, <br /> FOR OFFICE USE: -4 APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) W " <br /> - ENVIRONMENTAL HEALTH PERMIT PIJMP& WEII <br /> (COMPLETE IN TRIPLICATE) -� - WATER 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 Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address C7 i34 Tr,I4C " oyfJ P 7- +chi 64 T„!; Z ,,, c City/Town S G cA,'re, <br /> Owner's Name Phone cel ��•. S -..� 7 <br /> Address City <br /> Contractor's Name J License 4_ Business Phone <br /> Contractor's Address -1'+`f C1Y t':. rf',7� Q rr�li(� �+ --- <br /> �-- —I ��CaLC_._.,.. Emergency Phone <br /> 4s Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No � <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDiTION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 6�-'PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> ` REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines --- Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Properly 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 /> ❑ IRRIGATION © GRAVEL PACK Depth of Grout Seal <br /> El CATHODIC PROTECTION ROTARY Type of Grout ' <br /> BK <br /> �DDISPOSAL El OTHER Other Information <br /> —)VP-Zs <br /> ` OPHYSICAL S,Q _ � �rt�p��e I sta�lad y: <br /> a <br /> PUMP INSTALLATION; �or—_ ►`� 7 Zp .�Q ..Q <br /> Type of Pump __._ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Dane <br /> PUMP REPAIR: ❑ State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter <br /> — Approximate Depth �jr <br /> Describe Material and Procedure <br /> :.v <br /> LL T T y 1 nrJ j�,( vvYfl n.J c r" C'W9h�q <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County `YQ� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. ` athi . ,� <br /> Home owner or itcensed agent's signature certifies the following:"I certify that in the performance of the work forwhich s rmit T11+-��1" <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 wZ I call for a Grout In pection pr r to grouting and a final inspctton. <br /> Signed X <br /> tie Title: A <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Date <br /> .Additional Comments: <br /> �/ U <br /> Phase II Grout Inspection f Phase IN Final Inspection <br /> Inspection BY Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- ❑ PEA SITE ❑ EACH ❑ January 1 A Received Janu <br /> B Y_ar Y 31 ❑ July 18 Received By July 3t <br /> BASE EXPI-ANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> yF.L AMOUNT <br /> FEE � � AMO <br /> � - ...__... ._ __ .. _.._...._ ... �'r'��J_'� — - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t�� 3 <br /> Rucaivcd by DOW RCceIPI No. Permit No, Iseun ce Dnto Meilotl Delivered <br /> . —APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 4601 E.HAZELTON AVE..P.O.Bos 2009 sTrW MTn� rx o�or, <br />