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ApplicationsWill Be Processed When Submitted Properly Complete S - S h L p y ai <br /> FOR OFFICE USE: APPLICATION `'d <br /> (For Non Transferable, Revocable, Suspe le) <br /> ENVIRONMENTAL HEALTH PERMIT QED' 5 1980Punnp&WELL � <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ALU l.� AL. . <br /> Application is hereby made to the San Joaquin Local Health Districtfora permifto construct and/or int SAN OPQUIrNijiRbed-This application is I <br /> made in compliance with San JoaaLlin Co int�`�Ordina ce No. 1862 and the rulesnd regulati f the San Joa in Local Heal h District. <br /> Exact Site Address /CLI _ d r f Q Town _/,W � <br /> Owner's Name Phone <br /> Address 107 8City <br /> Contractor's Name License# �_ Business Ph ne S3�S/fes <br /> Contractor's Address Snk Emergency Phone 7/ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes— x.— No 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ _ „PUMP INSTALLATION ❑ PUMP REPAIR❑ i <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic.Tank _ Sewer Lines tis. Pit Privy <br /> Sewage Disposal Field !?DIi� Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ <br /> CABLE TOOL Dia, of Well Excavation <br /> © DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing p <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ,�,r —o=, <br /> IRRIGATION . <br /> loft GRAVEL PACK Depth of Grout Seal ' <br /> ❑ CATHODIC PROTECTION I ROTARY Type of Grout i <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ' <br /> PUMP INSTALLATION: �* Contractor 4 " <br /> Type of Pump - r - H.P. <br /> PUMP REPLACEMENT: EI-State Work Done ' <br /> PUMP REPAIR: f ❑ State Work Done <br /> -DESTRUCTION OF WELL: Well Diameter <br /> * _ 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 /> Homeowner or licensed-ade`nt'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 forwhich this <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California." ' <br /> I wiy call for a Grout I eetion i <br /> j p p for to grouting-and a final inspection <br /> Signed X <br /> Date: �a t <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ; <br /> PHASE i � q ., <br /> Application Accepted By Date ` <br /> Additional Comments: <br /> Phase II Grout Inspection CI so IJJ Final Inspection '� �(�// <br /> Inspection By Date Date Inspection B 04 <br /> ' <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 & calved By.January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ , REMIT <br /> BASE EXPLANATION - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER- , <br /> - I <br /> Received by Date Receipt No. ermit No- Issuance Data Mailed Delivered <br /> .APPLICANT—RETURN ALL-COPIES-TO: -ENVIRONMENTAL''HEALTH:PERMIT/SERVICES .. 1601 E.HAZELTON AYE..,P;OrBox-2D09-r,-STOCKTON,.CA;95201- - <br />