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Applications Will Be Processed When Submitted ProperlyComplet 0 eL�P trrgn IneOwPpIl 4n. <br /> FOR OFFICE iJ�= APPLICATION 198 <br /> (For Non-Transferable, Revocable,S dable)r n 1 2 MP&WELL <br /> Y ENVIRONMENTAL HEALTH RMITS „��i1L� ,�OGK <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY GGp�y;� }C)r` D}SJ <br /> Application is hereby madetothe San Joaquin Local Health District for apermit toconstruct and/or�lri tol ,rkhereindescribed.Thisapplicationis <br /> made in compliance withSanSan Joaquin County Ordinance No. 1862 and the rules and regulations the San Joaquin Local Health District. <br /> Exact Site Address ! Q lecz <br /> r do `s City/Town <br /> IF <br /> Owner's Name 7ra 1/ iz a Phone <br /> Address -;� rGSF t City <br /> Contractor's Name E�� �/`� License# p �Business Phone o7 3 Ot <br /> Contractor's Address 5 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—Y _..— No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ S <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 /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION " '°'�❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC P06TECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 7� 4Z ' " " <-- <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 1r�3 State Work Done <br /> PUMP REPAIR: IX 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 /> }come owner or licensed agent's signature certifies the following:"I certify that in the performance of thework for which this permit <br /> is issued, l 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 w71171a Graut Inspection prior to grouting and a final inspection. <br /> Signed X r� Title: eA .4—.� Date: C1 <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: + <br /> Phase II Grout Inspection al Inspection 'f <br /> Inspection By Date Inspection Date O , n <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 13 PER SITE ❑ EACH ❑ January 1 & eived By 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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> o' �4_ cl <br /> Received by Date 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 STOGKTON,CA 95241 <br />