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Applications Will Be Processed When Submitted Proper. oIn9MP <br /> pplication. �• <br /> FOR OFFICE USE: APPLICA I j '�:i TU <br /> For Non-Transferable,Rev e,Suspendable) &WELL <br /> ENVIRONMENTAL HEALTH WBMf'41982 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> ��nn.�� t�''����. <br /> Application is hereby madetotheSanJoaquin Local Health DistrictforapermittocoSAUtJRarQ"itl ALbereindesyribed.yThis application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules anjiWal s DIfATWIClaquin Local Health District. <br /> Exact Site Address City/Town ;2 � , C <br /> Owner's Name Phone <br /> Address 2 7/1%/ A ",v, City <br /> Contractor's Name ilyke1` 19,1 � License# &,2-37:? Business Phone y 1 fl s <br /> Contractor's Address ���` /�mC I yU ? Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No R <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 67 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 11 DRIVEN Gauge of Casing <br /> 17 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done <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 /> Home owner 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 0 �h )✓i��J & 2.61—Title: Date: g`� <br /> raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By W Date Inspection By Date <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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> y n DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS I' <br /> PRORATION / / C) <br /> PLUS �C1 C (h / UL-11 , t <br /> PENALTY <br /> OTHER /h C S C r a CA..,{v� 3— L' Yl�-!� .0�r� ✓} /' <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.Boz 2009 STOCKTON,CA 95201��s <br />