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Applications Will Be Processed When Submitted Properly Completed. B' a �bhd Ic n� <br /> FOR OFFICE USE: APPLICATION <br /> ry (For Non-Transferable, Revocable, Suspend i� <br /> k,' MP&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT �U� 2 ���� !� <br /> QUALITY <br /> (COMPLETE IN TRIPLICATE) WATER Q JQAUIN LOCAL <br /> hApplicationishereb made to the San Joaquin LocalHealthDistrictfora ermittoConstruct and/or ins 15If8tggT <br /> hisapPlicationis <br /> made in compliance with San Joa� County Ordinanc Nom. d,the rul reg ns of the an Joaquin Local Health District. <br /> � <br /> Exact Site Ad h e44 <br /> C� <br /> Owner'sName Phone II . <br /> Address r CityI� <br /> Contractor's Name License# Business Phone �' 6 L30-7 <br /> Contractor's Address Emergency Phone I� <br /> f Is Certificate of Workman' Compensation Insurance n Fil With SJLHD? Yes - - No I� <br /> ' TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION I] DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field -Cesspool/Seepage Pit Other v <br /> Property Line Private Domestic,Well Public Domestic Well IM <br /> INTENDED USE - TYPE OF WELL <br /> © NDUSTRIAL 13 CABLETQOL ,�y Dia. of Well Excavation <br /> I DOMESTIC/PRIVATE ❑ DRILLED, Dia. of Well Casing _ <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing II <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal IM <br /> t ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER _ ther Information `I <br /> ❑ GEOPHYSICAL u ce Seal Installed By: �4 fj' <br /> PUMP INSTALLATION: Contractor 0 <br /> Type of Pump AP. b'✓ <br /> PUMP REPLACEMENT: �,. ❑ State Work Done <br /> PUMP REPAIR: ❑ .State Work Done Ie <br /> DESTRUCTION OF WELL: <br /> }. R{Nell Diameter R- Appro imate D pth I <br /> Mate r'al and Prod - - - - w - <br /> I hereby certify that I have prepare this application and that the ork will be one in accordance with San Joaquin County <br /> ordinance laws, and rules and regulations of the San Joaquin Local'Health District. <br /> Ho owner or lic nsed_agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> "i' Is 1'shaWn t employ-any-person in'suchh neas to become subject to workman's compensation laws of,California." <br /> Contract is hiri or sub-contractin s' 1u cer Pies!he'f Iloliving:-"lµcerti,fy that in the performance of the work for which this <br /> permit is su I shall employ p ect work n's compensation laws of California." it <br /> I wi a for rout Ins ctio outing and final inspection. Al <br /> Signed ITitle: - Date: <br /> (Draw Plot Plano Re erse Side) J� u <br /> { FOfR".DEPAR MENT USE ONLY F <br /> PHASE I # II <br /> Application Accepted By Date' <br /> Additional Comments: II <br /> Phase II Grout Inspection Pha a III Final Inspeclio <br /> I <br /> Inspection By Date Inspection 39 <br /> Date � �' <br /> ,i <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT L-PER SITE ❑ EACH - ❑ January.1 8 Received By January 31 ❑ July 1 &'Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> ' BASE EXPLANATION AMOUNT DUE ! CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by, Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI$ERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br /> l .ii <br />