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Wgn <br /> (Applications Will Be Processed When Submitted Properly Completed.ue p��fq ko O� F13M►+ 1979" <br /> FOR-OFFICE USE: APPLICATION �3L� 1 <br /> (For Non-Transferable, Revocable,Suspendable) IOAQL}I1P� �-WELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN J <br /> WATER QUALITYHEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work,herein described.This application 1s <br /> 1862 and the rules and lations of the San Joaquin Local Health District. <br /> made in compliance with San Joaquin County Ordinance No. <br /> Exact Site Address <br /> S. C ��,,� City/Town 3 <br /> �� Phone 6 D <br /> Owner's Name City ZS C <br /> Address / Business Phone y <br /> Contractor's Name _7' A License# _ <br /> Emergency Phone s.4 „�- <br /> Contractor's Address Al /� No <br /> m <br /> Is Certificate of Workan's Compensation Insurance on File With SJLHD? Yes—f�`— <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 13RECONDITION El DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ N <br /> REPLACEMENTS Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines , <br /> 4�-,.-..,.• ,. Other <br /> Sewage Disposal Field Cesspool/Seepage Pit (q <br /> Property Line Private Domestic Well Public Domestic Well n <br /> fll <br /> INTENDED USE TYPE OF WELL. 0 <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout y <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: tR <br /> State Work Done V <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> We11 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 in accordance with San Joaquin County 4` <br /> ordinances,`state laws, and rules and regulations of the San Joaquin Local Health District. <br /> .:k=:. <br /> Home owner dr licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> Hissued, l shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> is hat in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifies the following:'l certify t <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> j I will fora Grout Insp ction prior to grouting and a final inspecti - <br /> -� e 9 _ <br /> Title: Dat <br /> Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPAR MENT USE ONLY <br /> PHASE I - Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Ph Final In cif <br /> Date Inspection By � °� � a <br /> Inspection By t� <br /> ❑ UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT 31 <br /> Fee IS DUE: [I ANNUALLY PER <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASF EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> i PLUS <br /> 1 PENALTY <br /> I OTHER <br /> I aTrIFR <br /> 777 --1 3a r. <br /> j, Received by Date' Receipt No. <br /> Permit No. ssuance Date Mailed Delivered <br /> 1601 E.,HAZELTON.AVE.,P.O Box 2009 STOCKTON, 5201 <br /> >.: .. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' _ <br />