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Applications Will He Processed When auumitted Properly Compl e� g 1 h +p 1' on. l� <br /> t:'z'�FOR-OFFICE USE: APPLICATION I <br /> 6(For Non-Transferable, Revocable,S ndable <br /> ENVIRONMENTAL HEALTH ERIlil 16 980 MP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> !� s _.:�y� ICAL <br /> Application is hereby made to the San Joaquin Local Health District for apemittoconstruct arGANn)aN�th�Vddl'I�ft. i -described.This application is <br /> made in compliance wit gy{in C ty r mance No. 182 a e rules and redk� au �l Loc^alJHeait�'D,lst <br /> Exact Site_di , �������(/ ity/Town <br /> Owner's Name Phone <br /> Address s city 1" <br /> Contractor's Name icense# ZtD�7 .lCiiness Phone 4 1 - <br /> Contractor's Address 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❑ <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 _ CIO <br />..- Property Line Private Domestic Well Public Domestic Well DI1 <br /> INTENDED USE TYPE OF WELL tN <br /> ❑ INDUSTRIAL T ❑ CABLE TOOL Dia. of Well Excavation a <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 /> I <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> © GEOPHYSICAL Surface Seal Installed By: j <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 13 State Work Done <br /> PUMP REPAIR- ✓ ❑'State Work rand <br /> DESTRUCTION OF WELL. Well Diameter Approximate Depth <br /> Describe Materrocedure <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 ofthe work forwhich 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 ' ' g or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> per is ed, I s all employ ns subject to workman's compen tion laws of California." <br /> wilt ut Inspect' n prio to grouting and a final inspec o 1 <br /> Signed X Title: Date <br /> (Draw Plot Plan on everse Side) <br /> A <br /> FOR DEPARTMENT USE ONLY <br /> Y <br /> PHASE I .. <br /> Application Accepted By *'+F"` Date <br /> Additional Comments: <br /> Phase II Grout inspection Phase III Final Inspection <br /> Inspection By Ir.�- Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January t &Received 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 - LAS. <br /> a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER yy <br /> OTHER # <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 STOCKTO 201 <br />