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Applications Will Be Processed When Submitted P_roperly_. ' le re� o g he lication. <br /> FOR OFFICE USE: '' AOLICATI' � <br /> (For Non-Transferable,+Reva i spn b e &WELL F- <br /> a 1981 , x , --� <br /> ENVIRONMENTAL�,HEALTH PERMIT , <br /> COMPLETE IN TRIPLICATE) WATER QUALITY,,,SAN-Jt A. I CI <br /> IAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit.toconstru Sd(bqi'Iil.yatapt -pR relndescribed.This pplicationis <br /> made in compliance vy Sa�aqu' C unty Ordin� 1862 1�the rules and regulations of the.San yu Local ist Ict <br /> Exact Site Addressr City/Town �•l <br /> Owner's N neone <br /> Address a + f Ili City • - ; <br /> Contractor's Name �!-'� _ 'License# Busine Phone; "7 <br /> Contractor's Address _mer ency Phone <br /> Is Certificate of Workman's Compensation Insurance on ile SJ <br /> With LHD? /YesI,�1/" No - <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 1:1 RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ �! %� l <br /> DISTANCE TO NEAREST: Septic Tank Se er ines Pit Privy <br /> Sewage Disposal Field pool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ID16ABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Instal ed y: F <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump - H.P. A <br /> PUMP REPLACEMENT: ❑ State Work Done f <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 or sub-contracting signature certifies the following:"I ce ify that in the performance of the work forwhich this <br /> per '2 ' d, I shall o ersons subject to workman's compen Ion laws of California." ` <br /> will glut Ins. do ionto grouting and a final <br /> Signed X Titl 2►tDate: /� y <br /> ' (Draw Plot Plan Reverse Side) t <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �) <br /> Application Accepted By I` Date / <br /> Additional Comments: <br /> Phase II Grout Inspection as II Fin f Inspection 7 <br /> Inspection By Date Inspection By z Date <br /> Fee Is Due: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH, ❑ January 1 8 Received By January 31 '' ❑ July t &Received By July 31 a <br /> REMIT <br /> BASE EXPLANATION BILLING. REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE _ <br /> i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. —Issuance Date Mailed Delivered a <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201. 1 <br />