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- I <br /> Appilcatlona Will Be Processed When Submitted Property Completed.Be Sure i a z19n ;mi 11172ro <br /> FOR OFFICE USE: APPLICATION &WELL <br /> IC (For Non-Translatable,Revocable,Suspendable) <br /> ENV IRONMENTAL• IEALT- PERMIT DEC i98i <br /> WATER QIIIALITY,;D ter it� VivoP� f�L <br /> {COMPLETE IN TRIPLICATE) '�"` �..�� <br /> Application is hereby made to the San Joaquin LocalHeakhDistricLfo�apermittoconstructand/or install thework,herel r <br /> made in compliance with San Joaquin County Ordinance No.1662 and the,rutes._and regulatl CltyRownSn Joaquin LdCat itdDis �TRlCT <br /> Exact Site Address S <br /> /. Q�vr•=�- t' Phone t t <br /> Ownef'S-Name ». <br /> ' <br /> " n r n': .' Cin <br /> Ail dress <br /> • c7�tf ''"'t'� License. /�x.37 , Business Phone <br /> .2Contractor's Name <br /> Contractor's Address _tt` � r �•��� 'Emergency Ffhone'� ''•t '' <br /> Is Certificate of Workman's Compensation Insurance on Fite With S JLHD? Yes No r <br /> f <br /> jCTIOND <br /> TYPE OF WORK (CHECK): NEW WELL❑D ' DENTEN OTHERCO❑, ITI PUMP INSTALLATION PUMP REPAIR I <br /> WELL CHLORINATION-E] WELL ABA ---- <br /> REPLACEMENT❑ es LinPit Privy DISTANCE TO NEAREST: Septic Tank Sewer Cesspool/Seepage Pit � Other � <br /> Sewage Disposal Field public Domestic Well <br /> Property,Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL _ <br /> 'INDUSTRIAL 1) CABLi TOCL - i Did of Wei <br /> Excavation <br /> ❑ DRILLED Dia.of Well Casing <br /> f I JJ DOMESTIC/PRIVATE <br /> ~..� <br /> DOMESTIC/PUBLIC © DRIVEN Gauge of Casing <br /> ❑ IRRIGATION - I. ❑ GRAVEL PACK Depth 61 Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY ;- Type of Grout <br /> ` Other information <br /> C1DISPOSAL 13 OTHER '* . <br /> Surface Sea! Installed By: <br /> El GEOPHYSICAL <br /> PUMP INSTALLATION:: Contractor <br /> H-P. <br /> Type of Pump <br /> PUMP REPLACEMENT: ©State Work Done ' �,1 <br /> PUMP REPAIR: State Work Done <br /> ! Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia!and Procedure " <br /> i <br /> 1 hereby certify that lhave prepared this application and that the work will be done in accordance with San Joaquin County r-- <br /> ordinances,state laws,and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agents signature certifies the following:"l 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 cerlines the following:-I certify that In the performance of the work forwnich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior-Aa grouting and a final inspectlon: <br /> Title: Date:. =15 <br /> Signed)( ,� (Draw Plot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> FApliation <br /> ASE I DatepcAccepted Bydditional Comments: n ecllon <br /> Phase It Grout In6peottoo <br /> [sate Inspection By hate r <br /> Inspection By___ - r y <br /> S Received By January 31 C3 July <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT [3kPER SITE ❑ EACH J- ❑ January 7 y i &{ieceiv REMIT <br /> d By uIy 31 <br /> ,r. <br /> t BILLING. REMITTANCE S- AMOUNT DU£ CHECKED <br /> BASE- � EXPLANATION PATE DATE REMITTED AMOUNT <br /> PEE' <br /> LESS <br /> I PRORATION <br /> 4-1. .. - <br /> PENALTY <br /> OTHER { <br /> • OTHER <br /> Mailed eliveretl <br /> Received by <br /> 4ate• Receipt Nu. Permit-No. - ass nce to D <br /> not E.HAZELTOIk AYE.,P.O.Dow 20W I➢TOCK1 OIl CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENYIRON�AENTAL HEALTFF pER11111TlSERYIGES 1F- <br /> I <br />