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' Applications WIII,Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. \` <br /> FOR OFFICE USE: Y� f /� APPLICATION /\\ <br /> ... T'- (p/pLA b (For Non-Transferable, Revocable,Suspendable) ) PUMP&WELL <br /> " ENVIRONMENTAL HEALTH PERMIT / <br /> ' (COMPLETE IN TRIPLICAT .'���ZMinIW "gKi <br /> f,��'�ATER QUALITY ' <br /> Application is hereby made to the San Joaquin Local Health Di LZ Rc for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County fOrdiig�once No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address :W�1x619_�O�° °T 6Alamr 6 �9e° 'i CitylTown V,atm <br /> Own;r's Name __ Phone <br /> Address 7 S y 1— v✓ p City �� •� A <br /> ' Contractor's Name 9'4-as s6 " License s *7�Business Phone <br /> Contractor's Addres G..- AJ Emergency Phone <br /> Is Certiflcate of Workman's Compensation Insurance on F)a With SJLHD7 Yes y -_ No <br /> ' TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 0 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 /> ,r Property Line Private Domestic Well Public Domestic Well -� <br /> INTENDED USE TYPE OF WELL N <br /> ' ❑ INDUSTRIAL ❑ CABLE TOOL Die. of Well Excavation S <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Die, of Well Casing <br /> •❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ' 54 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: to <br /> ' PUMP INSTALLATION: - It Contractor <br /> d Type of Pump H.P. !Ed IrJ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> ' PUMP REPAIR:, State Work Done I' <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> - Describe Material and Procedure vL <br /> j� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I, <br /> ' d ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner orlicensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit l <br /> 1, 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 thefollowing:"I certify that in the performance of thework forwhichthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wpl call for a Grout Insp to priO o g ting an linal inspection. <br /> ' <br /> Signed X6nle: rntLf Date: 'L <br /> (DrawPlot Ian on Reverse Side) <br /> .. FOR DEPARTMENT USE ONLY <br /> PHASE I C" / <br /> ! Application Accepted By \ Date <br /> ,' Additional Comments: ` - - . <br /> p Phase II Grout Inspection Phase 111 Final Inspection a+'^ <br /> Date <br /> Fee <br /> Inspection By7'✓t f?!I -'" Date 6 " <br /> 1napection By <br /> J Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE -❑ EACH ❑'January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> ' I! BILLING REMITTANCE 5 <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DAT REMITTED AMOUNT <br /> f <br /> : FEE <br /> I• <br /> LESS <br /> ' PRORATION <br /> PLUS <br /> PENALTY <br /> ' N OTHER I ' <br /> n OTHER <br /> ' u Date. Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received 6y <br /> ,I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH pERNRreERVIGEa 16111 E.NA2ELTON AVE.,P.O.sox 2009 STOOKTON,Op 85201 <br />