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A c Submitted Properly Completed.BeSureTo SignThe ppncauon. ; <br /> FOR OFFfCE USE: T77- 17ST <br /> APPLICATION <br /> (Far ransferable, Revocable,Suspendable) 9 WELL <br /> `a I <br /> MAY 12 198IENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) ,��,, WATER QUALITY <br /> Application is hereby madeislSak- e84Ur L6c6(lGALi)istrictforapermittoconstructand/or install the work herein described.,T)i is application is <br /> made in'compliancewit �a No. 1862 and the rules an eg lotions of the S a uin Loc H ' riot <br /> Exact Site Address City/Town <br /> Owner's Nam Pho4Dnqs <br /> I <br /> Address City ' <br /> Contractor's Name License# BusiPhone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on ile With SJLHD? Yes No <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 Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL. ❑ GABLE 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 <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 T <br /> Describe Material and Procedure <br /> r - L <br />'- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 41 <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 Ze ' t to workman's compensation laws of California." <br /> Contra i ' cj a sub-contracjing�signature certifies the falthat in the performance of the work forwhich this <br /> per is s I shall rhploy Gerson subject to workman's aws of California." <br /> 1 11 c a t spection Hor rout and a final iSigned XTitle: Date: <br /> (Draw Plot Plan o Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � S-8-181 <br /> Application Accepted By - ¢ Date <br /> i Additional Comments: <br /> Phase II Grout Inspectionas III Final Inspection .yam <br /> Inspection By Date Inspection By Date%_? <br />! Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PE9 SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE / L TM� <br /> LESS <br /> PRORATION <br /> PLUS <br /> 1 PENALTY <br /> 1 OTHER <br /> OTHER <br /> i <br /> Received by Date Receipt No Permit No Is ante to Mailed Delivered <br /> I; APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />