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-�+ Applications Will Be PrOCessed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> i FOR OFFICE USE: .0- s w APPLICATION <br /> {For Non-Transferable,Revocable,Suspendable) <br /> ►� ENVIRONMENTAL HEALTH PERMIT PUMP&WELL <br /> ( (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ! Application is hereby madetotheSen Joaquin Local Health Districtfor a permit to construct andforinstall the work herein' described.This application is <br /> ' made in compliance with San Joaquin Coun Ordnance No. 1862 and t les and regulations of the San aquin Local Health District. <br /> Exact Site Address <br /> _ City i r <br /> Owner's Name P f <br /> Address , �O <br /> Contractor's Name <br /> City <br /> Contractor's Addres License#�77�'/ Business Phone •- 0�. <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation llsuf3pce on Fil ith SJLHD? Yes LC <br /> No <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN❑ RECONDITION❑ DESTRUCTION® <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION 41• pUMp pEpAIR❑ <br /> C� <br /> REPLACEMENT❑ 5 <br /> DISTANCE TO NEAREST: Tank <br /> _ZZ <br /> 9_ttic / f <br /> P <br /> r,2 Sewer Linas_IjQjd. Pit Privy <br /> a t Sewage Disposal Field 42424/ '_ Cesspool/Seepage Pit Other I r <br /> r Prop_arty Line -�� Private Domestic Weil y ' ; Public Domestic Well <br /> INTENDED USE i TY'PE OP WELL <br /> ,�, IIAL —•-�-'�RBLE••TOOL Dia. Of Well Excavation_ <br /> UKOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DOMESTIC/PUBLIC ❑ Dia. a Well Casing <br /> DRIVEN Gauge of Casing <br /> ❑ IRRIGATION k. ❑ GRAVEL PACK " Depth of Grout Sea! <br /> ❑ CATHODIC PROTECTION ❑ ROTARY t ti — <br /> ❑ DISPOSAL <br /> TYI�e of Grout <br /> ❑ ; + ❑ OTHER Other Information <br /> GEOPHYSICAL rface Seal Installed By: I <br /> PUMP INSTALLATIOld Contractor <br /> Type of Pump <br /> PUMP REPLACEMhNTt ❑ State Werk Done A` <br /> PUMP REPAIR: '}. ❑ State Work Done <br /> DESTRUCTION OF Well Diameter ; <br /> ed- proximate Depth <br /> --r Describe Material and Procedure r�111101 ill 0_11-U"4Q22 oe <br /> 1 . <br /> I here*,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 ar licensed agent's signature cerllfies the followin :' <br /> l . g "IcertifythatintheperformanceOftheworkforwhichthispermit G <br /> is issued I-Shall not employ any pe?son in such manner as to become subject to workman's'compensation laws of;California.•• t <br /> Contractors hiring or sub-contracting signature certifies the following:"I certify that in the perfornrgnce of the work fdr which this <br /> permit,is issued, I shall employ persons subject to workman's compensation laws of California." i <br /> I will 'It fora Grout I ctia 3 <br /> *. prior to grouting and a final inspection. � ) <br /> Signed X I <br /> Dale,ate• +'2—�47 - <br /> (Draw Plat Plan on Reverse Side) J1y <br /> pHASE I <br /> FOR DEPARTMENT USE ONLY 4 f <br /> •� ;� _ <br /> I \ <br /> Application.Accepted By � d� <br /> Additional Comments: ' • Date Z <br /> se 1+1 �r4lttJnspection� b �, <br /> • ���� _: Phs- III Ffnaf'Inspection; <br /> Irtspectlon lay_ /L ' `�'�$a1e q. r <br /> sp o •By Date <br /> [ma�yy w. <br /> Fee 18 Due''❑'yygtNURLLY �' DER UNIT ❑ DER SITE ❑ EACH ❑ Jenu h <br /> ry a Received By January 31 ❑ July 1 S Received BY July 31 <br /> BASE .EXPLANATION BILLING" RENiITTANCt N'f, - REMIT. <br /> {' ,DATE. DATE REMITTED AMOUNT DUE CHECKED- <br /> FEE A _ +, AMOUNT'':-. <br /> LESS +�-• 04hJ- ;. <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER' •. .. . .... ' <br /> OTHER <br /> A _ti_.• ti <br /> Received by Date Receipt No. Permit No. I <br /> APPLICANT--A lesuan Date Malled Delivered <br /> ETURN ALL COPIES TO., ENVIROMMENTAL HEALTH PERMIT(SERVICEg <br /> f 16111 E.HAIELTON AVE.,P.O.Box yppq gTOGIrTON,CA D520I <br /> I' <br />