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Applications Will Be p'lcessed When Submitted Properly Complaled.'He Surf,"n Sign The Appticalbn. <br /> UrF117E usr APPLICATION <br /> (For Non-Translersble,Revocable,Suspendable) <br /> PUMP&WELL . <br /> ENVIRONMENTAL HEALTH PERMIT' <br /> QUALITY <br /> 7{..UrAs-L'ti7E I!1'CRiPLICATE) WATER Q . •;� �, <br /> 1.0 I:1..'r•aby made to Ihu San Joaqui n Local Health District for a permit to construct and/or Install the work herein described.This application is <br /> Glr,;,il.ulr_'r�wrih Sari Joaquin County Ordinance Nu.1862 Ind thtt rules and regulations of the San Joaquin Local Health Dist.tic L. # <br /> :� r.i ;Ilr.•,r4dr4b5 r�7"� .Z•-_ .- L.GC/.71.1�r� G.�C�. - _ .�. - City/l'own., �.-•�..,�-».�.«J <br /> r <br /> ;:fr I'l�Ilrl:, _ `T�OYr� ✓ M dr f'`'. Phone <br /> , <br /> ;•1.1f rL�s L [7 - - J.r.0 <br /> �SO.40, <br /> 21r <br /> NameLicenseusiness Phr.nowe{e .-r•w EmergencyPrionb <br /> t:( rilhc,atr_of Workman's Compensation Insurance on Filelth SJLHD'f Yes No :x <br /> TYPE OF WORK iCHECK): NEW WELL E3 DEEPEN❑ RECONDITION❑ DESTRUCTION❑ <br /> CHLORINATION❑ WELL ABANDONMENT <br /> OTHER© LIMP INSTALLATION MP REPAIR❑ v ' <br /> Yr 'T <br /> HEPLACEMENT❑ T. q <br /> [JISTANc E TO NEAREST; Septic Tank Sewer Lines `-- ,�; , Pit Privy r (,. <br /> Sewage Disposal Field.- -Cesspool/Seepaga,Pit_„ __Y _ Other__—.. ` } <br /> Property Line--Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL is <br /> ��, <br /> �,.�, INDUSTRIAL 13 CABLE TOOL Dia.of Well Excavation <br /> >1 DOIAESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing � <br /> L` inILSTIC1PUB LlC ❑ DRIVEN Gauge of Casing —._..— <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> © CATHODIC PROTECTION ❑ ROTARY TypeofGrout <br /> 1 DISPOSAL ❑ OTHER --- --- _ Other Information <br /> GEOPHYSICAL v Surface Seal Installed By <br /> PUMP INSTALLATION: Contractor— . <br /> Type of Pump; S�r _/Jt_(a✓ /� H.P. <br /> � <br /> PUMP REPLACEMENT: ❑T Stale Work <br /> y PUMP REPAIR: 0 State Work Done.. __— <br /> DESTRUCTION OF WELL: Well DiameterVApproximate Depth <br /> Describe Material and Procedure <br /> t r <br /> I herby 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 /> i 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 ill call for a Grout Ing p ion rior uting and a final inspection. r. <br /> { Signed — . <br /> t, _ Title: Ylr�i�l _ Date: _ <br /> t}: (Draw Plo Ian on Reverse Side) <br /> FOR EPARTMENT L"!9E.ONLY . <br /> f PHASE <br /> •.t <br /> i Application Accepted 6y <br /> Additional Comments <br /> Phase li Grout Inspection so �inalIn�tion; <br /> inspection B - <br /> 13 Y Date�_._�.- _. .._. inspection BJ/8'� Date <br /> Fee Is Due: 0 ANNUALLY ^'❑ PER UNIT _ F❑ PER SITE []EAC FI ❑ January t&ReceiveA-By January yt ❑ July 1 d Recerrea PJy Jury 3t �! " <br /> — — REMIT 1 <br /> BASE EkPLANA7ION I BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> S. <br /> fj I J I DATE DATE REMITTED AMOUNT "_ <br /> IEE I �i` �f 1 : <br /> -rel U•. I ° �'��. <br /> r <br /> r,Ezr ..L r'i <br /> r <br /> -�-- <br /> .. n,,r•• ,`� RucerPl No Permrl No Isawnea 011ie' Mme" pelneretl .7 W;y <br /> 1.c.ul f--In70'In ALL COPIES TO[ ENVIRONMENTAL-HEALTH PERMIT1eERVICES -1401 9,HAZELTON AVE..PA.sal X eTOCKTOM,CA NM <br /> ' i Y <br /> ry <br /> Yib 1 <br /> r �o. <br />