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I Applications Will Be Processed When Submitted Properly Completed. Be Sure To The Application. <br /> 'APPLICATION <br /> r_ .E USE: �, . <br /> (For Non-Transferable, Revocable, ib <br /> , �n <br /> P &WELL <br /> s <br /> ENVIROPIMENTAL y MIT ��" . <br /> } WATER Q Yl,� <br /> (COMPLETE IN TRIPLICATE) <br /> Application ishereb , __gotheSanJoaquinLocalHealthDistric4forapermitt tructr)lonstallth� rein deseribgd.This application is <br /> madelwltlkncgwfth San J a in County Ordinance No. 1862 and the rules and regulations(�{��*1 a um Local Local"ealth District. <br /> Exact Site Address . <� E <br /> jGijt'7T"" T2 <br /> Owner's Name __dQ ti �^f G one <br /> Address City '" <br /> Contractor's Name /0 License#_L JBusiness Phone <br /> Contractor's Address __ � Q n �9 �7 Emergency Phone �z, <br /> Is Certificate of Workman's Compensation Inrance on File With SJLHD? Yes No - <br /> TYPE 9jFl ! ( GHEGK.= NEW WELL�1 DEEPEN❑ RECONDITION DESTRUCTION❑ !` <br /> WELL CHLORINATION ( WELL ABANDONMENT 11 OTHER C1 PUMP INSTALLATION PUMP REOFCIRQ <br /> _,;..--- . _ _ of <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy , V <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I, <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ D,O.M�STIC/PUBLIC ❑ DRIVEN Gauge of Casing �b <br /> inIRfSC ON ❑ GRAVEL PACK Depth of Grout Seal <br /> S,�'CY-C_ATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Ty e of Pump H.P. <br /> PUMP REPLACEMENT: State Work Doneaca��+ <br /> 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 /> 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." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which 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. <br /> Signed X i eL Tltle: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> ` FOR DEPARTMENT USE ONLY A-f IU <br /> PHASE I <br /> Appuoat-fon Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection P se III F'i1 Inspection <br /> /2 —/G <br /> inspection By— Date Inspection By Date f% <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH C3 January 1 &Received By January 31 ❑ July 1 8 R ceived By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> EE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> i<7 <br /> Received by Date Receipt No. Permit No. Is ance qate Mailed Delivered <br /> ...,­­Or-IPU Al I rnPICC Tn• FNVIR/1MYFNTAI HFAI TN PFRMIT/CFRVIr.FC tnn1 F.HA7ELTON AVE._P.O.Box 2009 STOCKTON.CA 95201 <br />