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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICGUSE: <br /> A, '' I�PPLICATION <br /> (For Nan-Transferable, Revocable, Suspendable) PUMP&WELL <br /> C ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) .. _ «a>� 'i Wt� d&W�i�IATY - _ _ c2�OugO_02 <br /> Application is hereby made to the San Joaquin LocalHealth bisiricffore- r tononstruct antlforinstall the work herein described.This application is <br /> made in compliance with Sa Joaquin Co�upty Ordinance No. 1862 and the'rules and regulations of the Sen Joaquin Local Health District. <br /> Exact Site Address Nr�O IV G9r/ ��y��'��Q ­Sctie &Vff f/Z City/Town <br /> Owner's Name ft? Phone r <br /> AddressCity �h <br /> Contractor's Name tbl/ 10� License# 41111r Business Phone' �.'t �"i-'�76? <br /> Contractor's AddressOeALK AS ti... n u:Emergency Phone -•. %^e � _^ -M... <br /> Is Certificate of Workmen's Compensation Insurance o File With SILHD7 Yes No <br /> I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN O -RECONDITION❑ DESTRUCTION❑WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRS <br /> REPLACEMENT❑ r <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 bomestiq Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Die. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 99-IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑.DISPOSAL ❑ OTHER Other Information <br /> i. ❑ GEOPHYSICAL Surface Seal InstalledBy:! <br /> ` <br /> PUMP INSTALLATION: Contractor C� 551k!VIM <br /> W 1 <br /> Type of Pump Tse✓ 3w!_ u_o_ <br /> PUMP REPLACEMENT: ❑ State Work Done f <br /> PUMP REPAIR: C9 State Work Done <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and'Procedure <br /> i . <br /> hre eby certify that I have prepared this application and that the work will be done in accprdance with San Joaquin County <br /> ordinances;state laws, and rules and regulations of the San Joaquin Local Health District. i <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the worktor which this permit <br /> Is Issued-I shall not employ any•person•in such manner as to become subject to workman's,compensationI°�ws of California." <br /> Contractnes hiring or cub-eontrectirfg sighature cerlhlea the following:"I certify that In the performance of therw�ork forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California" ' <br /> I villil call for a Grout Inspectiot`T'Q,dor o dull snd a I aHnspection. 4_ `— <br /> Signed / +' \d n � ddddd�lrly-� ?�/rx . :Dale• . <br /> (Draw Piot PI on Reverse Side) . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I +'# - p <br /> Application Accepted By A(—L C.t OS Data <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase,III F <br /> 1 <br /> Inspection By - I Date Inspection"B 9 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J 1 a Received EWJanuaiy 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE.. § <br /> BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CHECKED <br /> _J__ AMOUNT <br /> FEE ex —I 1 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY .. <br /> OTHER t - <br /> OTHER <br /> Receved by Date Receipt No. Permit No. :_ Iv nce De _ a4iletl Delivarr>d' <br />