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ications Will Be Processed n Submitted Properly Comple � . rSignThe A Ilcation. <br /> FOR OFFICE USE: ry 1982APPLICATION ': � <br /> D C L C 2 r-, (For Non-Transierable, Revocable,Susp le) 10 <br /> &WELL <br /> N LOWRONMENTAL HEALTH PERMIT <br /> SAi� JC�(�U ,r^ � <br /> HEALTH DISTRICT WATER QUALITY ,��,,P�aT <br /> (COMPLETE IN TRIPLICA <br /> SPT y <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or instwork herein described.This application is <br /> made in compliance with S�ajn Joaquin County Ordinance No.1862 and the rules and regulations of the San <br /> /�Joaquin Local Health Distric � <br /> Exact Site Address -/ 33 4s fin' 4 d� Bell � City/Town L�/��ISD 4___ �1-3-� d <br /> Owner's Name /"/ ,5s/ Phone Y� ��_Q <br /> Address ^ 'S '� Ur— city��56 (2A 42A/ <br /> Contractor's Name License#s�J'r'S Business Phone <br /> Contractor's Address A �� Emergency Phon <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes__ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION,I PUMP REPAIR i <br /> REPLACEMENT❑ O <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �Q <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> r <br /> INTENDED USE TYPE OF WELL j <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED" Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION.. ' ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL A! S Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor /v <br /> Type of Pump: `S / H.P. <br /> PUMP REPLACEMENT: State Work Done IY57s91�,� Q �� P �Oe-/0! <br /> PUMP REPAIR: ❑ State Work Done <br /> i DESTRUCTION OF WELL: Well Diameter Approximate Depth 3d� 0 <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner 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." d <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will I for a /ro�u Inspection p for to grouting and a final inspection. <br /> y- <br /> Signed X C(��(D �' Title: fc'/ 0 lo C Date: /;2 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br />� PHASE I <br /> Application Accepted ByDate <br /> Additional Comments:_ A�� <br /> Phase II Grout Inspection ase II Inal Inspection <br /> t Inspection By- .�_Q�-- Date Inspection By T Gate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received January 31 July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 45 <br /> LESS <br /> f PRORATION <br /> Ilr PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> $� C> X �/ <br /> Received by - Dale Receipt No. Permit No, issuance Date Mailed Delivered <br /> ..I APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />