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- -A plications Will Be Processed When-Submitted Properly Co"et a To Sign The Application. <br />{ 'FOR oI+`F- sE: APPLICAT� <br /> �.. ►„ (For Non-Transferable, R o e us endPple <br /> P��,c��? ) CUDM <br /> WELL <br /> ENVIRONMENT ALTH. laff P�' - - } <br /> i (COMPLETE IN TRIPLICATE) AL� 4 _ <br /> Application is hereby made to the San Joaquin Local Health District fora toA ructi� �Ji\`'��I the work herein described.This applicatioyti is <br />{. made in compliance with San Joaquin Co ty Ordinance o. 862 and t rules and r. I -CU of the San Joa uincoal Health District. <br /> Exact Site Address A City/Town Q <br /> Owner's Name Phone O <br /> Address _ City <br /> Contractor's Name icense#��Business Phone 3 ;,-L <br /> Contractor's Address Emergency Phone a <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yetis_ �. No t <br /> TYPE OF WORK (CHECK): NEW WELL; DEEPEN ❑ RECONDITION 11. DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLAT103)Z PUMP REPAIR 11 <br /> REPLACEMENT❑ W <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy F , <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Lin,_5(�'Private Domestic WeIIQ�Public Domestic Well <br /> INTENDED-USE-_ TYPE OF WELL_.- f <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> /� `�/ <br /> E <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �)_* /?e- <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout !lett e- \ <br /> ❑ DISPOSAL ❑ OTHER Other Information -. <br /> ❑ GEOPHYSICAL Surface Seal I stalled By: <br /> OwNcie— <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pump H:P. <br /> PUMP REPLACEMENT: ❑ State Work Dane ._ <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r 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. N. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich 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 bertifies 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 /> I will call for a Grout In pectio prior to grouting and a final inspection. <br /> Signed X � Z�AW4elns� Title: 40 A A N A4 Date: f O <br /> (Draw Plot Plan on Reverse Side) <br /> ' FOR DFPA TMENT USE ONLY <br /> PHASEt <br /> Application Accepted By Date T7 d d <br /> Additional Comments: <br /> Phase II Grout Inspection Ph 111 Final Inspection <br /> 'Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 0<'PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DAT DATE REMITTED AMOUNT <br /> FEE _ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> 1' <br /> OTHER <br /> r <br /> Received by Date Receipt No. Permit No Is uanc Date Mailed Delivered ` <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT.ON AVE.,P.O.Box 2009 $TOCKTON,CA 95201 , <br />