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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO.- FICE USE: APPLICATION <br /> cr,t /. '0 (For Non-Transferable, Revocable, Suspendable) <br /> 9 PUAAP &WELL <br /> ENVIRA MENTAL HEALTH PERMIT <br /> (COMPLETE 1N TRIPLICATE) fSa�nJ <br /> � ATER QUALITY <br /> Application is hereby made to theo c I eafthDistrict or ructand/or install the work herein described.This application is <br /> made in compliance In regulations of the San Joaquin Local Health District. <br /> FExact Site Address e t,1rs r '9 "A 4 City/Town <br /> , Owner's Name S� m �. rt Phone <br /> City <br /> Address 3 G dp �Yt <br /> 3i Contractor's Name f , License #1 .e— 8� Business Phone? Z� 7''t <br /> Contractor's Address Ia2Ua _ ( y Tltl Emergency Phone <br /> F <br /> is Certificate of Workman's Compensation Insurance on File With"SJLHD? 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❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> ti Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia..of Well Excavation <br /> F, 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> �-± ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> Y ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' ' ' t <br /> Type of Pump - ,rYL_thr H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 fallowing:"I certify that in the performance of the work for which this <br /> t permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspe do prior to routing and a final inspection. <br /> FSigned Title: _ _ Date: f <br /> lo (Draw PI Plan on Reverse Side) <br /> F DEPARTMENT USE ONLY <br /> PHASE I <br /> . ` Application Accepted By w Dat <br /> I Additional Comments: <br /> Plias i r spection P as I of Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 © July 1 &Received By July 31 <br /> REMIT <br /> Fi' BASE EXPLANATION BILLING REMITTANCEAMOUNTDUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESSs:1 <br /> w PRORATION ­ <br /> PLUS y <br /> ,PENALTY <br /> Fil- <br /> OTHER <br /> OTHER x <br /> to{{,£ � U ' '_`+3te ° :�E CrLt ti4� �.r'E:'.,�C}'4azt 4�#�.s�"r��.�'�^ _.-hex{�?k�'r�:�al a «~.�R�f•Ct "- 4.ra� "^,�° :F a+ r.�'ti1 Y e�+uk-� <br /> . --..l,r.�LACfaEx, ar"3..."i.ri'x.-. ,-:.i3d�.�;t�'�ic�+i5��'�? 7'•;:is'4J�..�4�` �lYk�'.�4' 4h�i�ftu�:�.?",}X14,r..yh•,�57�#` h!�. 24�5` h�,� �T4. .,,,t„'.-rw'Xla!'t'"�`�f�.'rS <br />