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Applications Will Se Processed When Submitted Proper) mpRf� S> eV 7 <br /> : calion. <br /> Ff�,,R,orF.i�E USE: APPLICA I "1 (0�) <br /> (For Non-Transferable,Revo ,Suspendable) Mp <br /> &WELL <br /> (S-) <br /> ENVIRONMENTAL HEALTH ��yT41982 <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> AppiicationisherebymadetotheSanJoaquinLocalHealthDistrictforapermittoco aA AQUthLQprein described.This application is <br /> made in compliance with San Joaquin County Ordinance No; 1862 and the rules andJ"@uM_E&J cMWUaquin Local Health District. <br /> Exact Site Address �QO City/Town <br /> Owner's Name Phone } <br /> City <br /> Address 3 0 o W <br /> Contractor's Name .ir.� n3 r License# Business Phone <br /> 3 3 <br /> Contractor's Address �9�7 Emergency Phone <br /> ��� ` � <br /> No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Phone <br /> ❑ �. <br /> TYPE OF WORK (CHECK): NEW WELL IJ DEEPEN 11 RECONDITION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ 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 /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> � OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0,GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 0 <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work Will be done inaccordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify:that in the performance ofthe work 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 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 compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final Inspection. <br /> P, .., �, 9 �.r� , Title: Date: �- �-$.� <br /> Signed X �. }Y� n ^^ ��, <br /> (Draw Plot Plan on Reverse Si e) � - - - ----� <br /> FOR DEPARTMENT USE ONLY <br /> • PHASE 1 0J Date <br /> Application Accepted By <br /> Additional Comments: <br /> Pha e I Grout Inspection Phase II FinMinspectlon <br /> Inspection By <br /> Date Inspection By r to <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACR. ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE "t- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - Date, - ReceiptNo.!- Permit No I ante to Mailed Delivered <br /> # 1601 E.HAZELTON AVE.,P.O.Saw 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />