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_. USE: APPLICATION <br /> Non-Transferable, RP 7a <br /> , <br /> ti+U�17i'a'tUii+1}!Yl <br /> r -- - PUAAP&WELL. <br /> ----------------- <br /> ENVIRONMENTAL HEALTH PERMIT r <br /> i.COMPLETE IN TRIPLICATE) WATER QUALITY <br /> !kpplication is herebyinaaeto theSanioaquin Local Health District for a permit to construct and/or instailthework herein described. This application is <br /> roade in compliance with San Joaquin Cu my Or finance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> m-cxact Site Address Lf -. � _ _.. City/Town <br /> Owner's Name 11 �- 3 G -y G,u'i :.-.--.----- Phone <br /> Address rf .S; City_- 1n�2C_Y ---._.-_ <br /> I <br /> ontractor's Name - /01cense#,Z4t9 / _ Business Phone �- <br /> :;ontractor's Address -� ---- -- -- Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes e _ No <br /> ,STYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> NELL 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 /> Property 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 /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump_ H.P., U <br /> PUMP REPLACEMENT: State Work Done-' ,'--_- 1� <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 /> Homeowner or licensed agent's signature certiffes 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 following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> Iwill ail for a Grout Inspection prior-lo ,outing and a final inspectL D. <br /> Signed X i` � . ' Title: . Date: ��-zF;e - <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By -- - Date <br /> Additional Comments: _. <br /> Phase 11 Grout Inspection Ph/seII Final Inspection <br /> Inspection By ___.....- - Date Inspection By <br /> __.._ Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receivetl By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> IAfI N GlefjP.f Al da-�_ i <br />