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Applications Will Be Processed When Submitted Properly Comp Be Sure To Stbi1 1fie pli n, <br /> FOR�FFICE USE: APPLICATION l 00 &A"e /Afp <br /> C' (For Non-Transferable, Revocable, Suspendableq� 41 1`W <br /> ENVIRONMENTAL HEALTH X979 MP&WELL <br /> -WATER uaLiT�r �Eq��'��UIN � <br /> (COMPLETE IN TRIPLICATE) Q I� OC <br /> Application is hereby made to the Sans Joaquin Local Health District for a permit to construct and/orinstallt�e;7li?; tpindescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 186.2 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Ve 4,= � City/Town 4�,i e—ii <br /> 2 <br /> Owner's Name PhoneCV <br /> Address City <br /> Contractor's Name cense#� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation,Insurance on File With SJLHD? Yes 4l No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT'❑ <br /> i <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 ❑ 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 Installed By: �+ <br /> PUMP INSTALLATION: Contractor &4 A � + <br /> Type of Pump Q17 H.P. I _ <br /> PUMP REPLACEMENT: ❑ State Work Done " <br /> PUMP REPAIR: State Work Done--4L.Qp1cOQ1C <br /> DESTRUCTION OF WELL: 11 <br /> 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 performanceof the work forwhich 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 all fora t Inspection prior to grouting and a final inspe tion. <br /> Signed X ✓— � = Title: � � Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY i <br /> PHASE I ,, p <br /> Application Accepted By Date d 7 i <br /> Additional Comments: <br /> Phase H Grout Inspection Phase 111 Final Inspection 1 <br /> Inspection By Date Inspection By Date <br /> i <br /> Fee Is Due: ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 .y <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED ' <br /> DATE ATE REMITTED AMOUNT <br /> 5 <br /> FEE �,J <br /> LESS. y <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> 1 <br /> OTHER F77.11 1 <br /> OTHER <br /> Received by Date Receipt No. Perr it No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES '116011 E.HAZELTON AVE.,P.O.Box 2009 STOCI(TON,CA 9 1 <br />