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Applications Will Be Processed When Submitted Properly Completed. Be Sure Tozz n aAppRCation. <br /> APPLICATION { <br /> FOR OFFICE USE: � rA . 1� h�� <br /> (For Non-Transferable, Re QCab Ie S�e�dablt) '"l' &WELL <br /> ENVIRONMENTAL H A <br /> (COMPLETE IN TRIPLICATE) ,WATER QUA },. <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or installtl evvfD%164ein described.This application is <br /> made in compliance with San Joaquin Ordinance No. 1862 and the rules and r gulatipns i ,g6�1 rpt uln Local Health District. <br /> P q y ., x rS ;i '•tC)t}xlrTf3 rl �1� — <br /> Exact.Site Address <br /> Phone <br /> Owner's Named ' <br /> City <br /> Address <br /> License# 73 'Business Phone <br /> Contractor's Name n <br /> Contractor's Address /? � �y / Emergency P oyle ' <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes •/ No <br /> TYPE OF WORK (CHECK):-' NEW WELL❑ DEEPEN"❑ RECONDITION❑ DESTRUCTION' t� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ "r <br /> REPLACEMENT❑ .— <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other �� 1 <br /> Property Line Private Domestic Well 1-Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> * MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing t <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: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: d�State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe,Material an6Procedure <br /> i CG <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. r <br /> Home owner or licensed agent's signature certifies the following:""I certify that in the performance of the work for which this permit <br /> is issued, 1 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 loompensation laws of California." d <br /> k' I will call for a Grout Inspection prior to grouting and a finale"inspection. <br /> Signed X <br /> Title: .Date: <br /> (Draw Plot Plan on Reverse S de) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Iy �' $2- <br /> _ Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phas II Grout Inspectional III FJ al Inspection / <br /> Inspection lay <br /> Date Inspection By Da1e �'!•Q'�3 <br /> ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 C] July 1 &Received By July 31 <br /> Fee IS Due; 13 ANNUALLY <br /> REMIT <br /> BILLING -_.REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED- �} AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> Received by <br /> Date Receipt Now;- -Permit No Issu ce Date Mailed'- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 7601 E.HAZELTON AVE.,P.D.80■2004 STOCKTON,CA 95201 <br />