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Applications Will Be Processed When Submitted Properly CompleL-A%,Snr gnplical tion. <br /> FOR OFFICE USE: APPLICATION <br /> - (For Non-Transferable, Revocable,-Suspea4I¢) P WELL <br /> VAiV IG�AO�.![f'J t-?s� <br /> ENVIRONMENTAL HEALTH PERM.IALTH D!STP!(;T <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY R w,. - <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San.Joa uin Count Ordinance No. 1862 and the rules a d re ulations of the San Joaquin caHealth District. <br /> P ! ! y gu q <br /> Exact Site Address_�[� t7J � Ag A City/Town e <br /> Owner's Name LDo 6 �?h • p: Phone <br /> Address s-t-� 3L? '71 w ;a ,.,., ,.: City <br /> Contractor's Name License#�W 0 Business Phone • o �y r- <br /> Contractor's Address ) 1 ' `I �_ F Emergency Phone SR•Fw-A'�- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes-��A- No p� <br /> TYPE OF WORK (CHECK): NEhN WELL 1:1 'DEEPEN ❑ RECONDITION❑ -DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION- PUMP REPAIR© <br /> REPLACEMENT W t . <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 " M s ❑ CABLE TOOL Dia..of Well Excavation <br /> IR DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK s 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. <br /> PUMP REPLACEMENT: State Work Done 0, "+ /r 7� L a <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 ha4'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. <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, 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 for which this s <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> - I will cal41o6krou nsio nor to grouting and a final inspects rr,. <br /> Signed X• -Title: .: Date <br /> (Draw Plot Plan on Re erse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ©10 <br /> Application Accepted By Date L <br /> Additional Comments: `} <br /> Phase 11 Grout Inspection - :' h e Final inspection T <br /> Inspection By 1 Date Inspection 9 Date Z 2 <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE 11 EACH ❑ January 1 Received By January 31 El July 1 &Received By Juty 31 <br /> REMIT A j <br /> BILLING REMITTANCE $ i <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ <br /> AMOUNT <br /> FEE- q <br /> LESS --r <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> a OTHER <br /> OTHER .F <br /> 69-775. . <br /> Received by – - ate - -Receipt No Permit No. _ – .%Issuance Date_ Mailed - DeliVered: - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />