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Applications Will Be Processed When Submitted Properly Completed. Be S re—ltk** li do <br /> I-JkgFFICE USE APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable <br /> ENVIRONMENTAL HEALTH PERMIT r , W&WELL Q <br /> �� <br /> tt / <br /> (COMPLET WATER IN TRIPLICATE) QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install tl J_rh csfibei�.Phis application is <br /> made in compliance w - <br /> h a Joaquin County Ordinance No. 186 n the rules and regulations of the Sa oaquin Local Health District. <br /> Exact Site Address 37 L • iz 7Wu-/°z City/Town <br /> Owner's Name MA,�U I ry In 6A it Phone <br /> Address 6 jqk"� City 4.SC <br /> Contractor's Name 1 &4, License# 6/0 Business Phone-&P �y <br /> Contractor's Address x!2613 /x L)n,> Emergency Phone -- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes._/u f1 No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRI� <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 /> IR 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 J <br /> ❑ DISPOSAL ❑ OTHER Other Information i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Ut <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 1' State Work Done R14—i&k '-L <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 wil II forGrou pecti n prior to grouting and a final inspect! <br /> Signed X Title: Date: .2 7-60 <br /> (Draw Plot Plan on Rev ere Side) <br /> FO DEPAR MENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date �� d <br /> Additional Comments: <br /> Phase II Grout Inspection P se III Final Inspection o� <br /> Inspection By Date Inspection By Z14Date <br /> Fee Is 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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r/ a P3 OS <br /> Received by Datb 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 STOCKTON,CA 95201 <br />