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Applications Will Be Processed When Submitted Properly Completed. B e 4gn The A plication. <br /> 4*W-QFFICE USE: APPLICATION qO,L�� <br /> For Non-Transferable Revocable S aft5le <br /> r <br /> ENVIRONMENTAL HEALTH P T Ga� �� �G P&W�L <br /> WATER QUALITY tj�' <br /> (COMPLETE IN TRIPLICATE) Q � N O <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in _P herein described.This application is 1 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of th an Joaquin Local Health District. <br /> Exact Site Address 3963 E. Fremont St. City/Town Stockton � <br /> Owner's Name Mr. & Mrs. J. Lemon Phone ggg;je 98 or 944-5686 <br /> Address 955 S. Adelbert City <br /> Contractor's Name M Chan S Water Systems License# 267696 Business Phone 931-3210 <br /> Contractor's Address `f3 eherryland ave. Emergency Phone same as above <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION El <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM <br /> REPLACEMENT❑ 9 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy f� <br /> t' 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 /> ❑ 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 W <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump submersible H P 3 <br /> t <br /> PUMP REPLACEMENT: La State Work Done pulled old pump and installed new pump <br /> i 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 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." i <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.Signed X Title: /, Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI7 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase It Grout Inspection Pha III F' a In e tion <br /> Inspection By Date Inspection By Date <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE L( <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER `' <br /> Received by Date ':Receipt Nb. •Permit No. Issuance Date Mailed Delivered-. <br /> F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ... 1601 E.HAZELTON AVE.,P.O.Box 2009-STOCKTON,CA 95201 <br />