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Applications Will Be Processed When Submitted Properly Complet M e&r&"g h�A lic t <br /> FOR OFFICE usE: APPLICATION ' <br /> -. (For Non-Transferable, Revocable ,Sus able)AU G 27, J"P&WELL <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> SAN JC`,A1Q IN LOCAL <br /> (COMPLETE IN TRIPLICATE) .WATER QUALITY am+ � <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/ort , j°v6ole1n�• ecribed.This application is <br /> made in compliance with San Joaquin,Co my•Ordinance No. 1862 and the rules and regulations,of the San 18aquin Local Health District. <br /> Exact Site Address t � City/Town <br /> —W e� � .�, <br /> Owner's Name _�, Phone. <br /> Address mY�-= r City r-k_ II. <br /> Contractor's Name Fa c/ �' a �!5 License#�< i®fC7 `_Business Phone�P 3 , <br /> Contractor's Address 9—ed-2-1 �`y ` '` It Emergency,P o e � � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesNoNo �� Q0 <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 I Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> 11 INDUSTRIAL <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal NI. <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout Iq� <br /> ]�C] DISPOSAL DISPOSAL ❑ OTHER Other Information N� V <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor III # <br /> Type of Pump H.P. ` <br /> PUMP REPLACEMENT: 1:1 State <br /> State Work Done - 1 <br /> PUMP REPAIR: Slate Work Done oW <br /> DESTRUCTION OF WELL: Well Diameter Approxi mff ate Depth ; <br /> Describe Material and Procedure �I <br /> �C fi <br /> I hereby certify that I have prepared this application and that the work will be done in accordanice with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. II 1 <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." . <br /> I 'I call fo Gr ns p c' n prior to grouting and a final inspection <br /> Signed X Title: Date: �� � i <br /> (Draw Plot Plan.on verse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By V � Date <br /> Additional Comments: <br /> Phase I Grout Inspection z " Via- Phase 1, Final Inspection <br /> Inspection By Date �R �Q-- 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 /> i REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> y��f} C�.�/ AMOUNT <br /> FEE S - 6 <br /> LESS - <br /> PRORATION - <br /> PLUS - <br /> PENALTY <br /> OTHER <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-96201 co <br />