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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ' <br /> FOR OFFICE USE: APPLICATION <br /> � ,- <br /> (For Non-Transferable, Revocable;Suspendable) PL)NIP&WELL <br /> 5 . (I „! � ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY- <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> made in compliance with SanJoaquin County Orad Ina ce No.1862 and the rules and regulations of the San Jo quip Lo al Health District. <br /> Exact Site Address J / � �f taOc� Z.N_ City/Town [ f� C/ <br /> Phone <br /> Owner's Name ., <br /> ,x. . City <br /> Address , <br /> Contractor's Name License Business Phone <br /> Contractor's Address <br /> z '= Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File 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 /> Cesspool/seepage Pit Other �� <br /> Sewage Disposal Field 4 <br /> Property Line.�4�- Private Domestic Well ] -E Public Domestic Well <br /> t INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL - ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> I <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ElIRRIGATION 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 /> Horne 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 p sons subject to workman's compensation laws of California." <br /> I wit all for a rou nspe o prior to grouting and a final-inspection. f <br /> Signed X .Title: 'Date: <br /> (Draw Plot Plan on Re se Side) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> ,. Date <br /> Application Accepte By <br /> Additional Comment t <br /> u P ase II Grout inspection ha a III Final Inspection <br /> Date_ , Inspection By. Date <br /> Inspection Bye <br /> Fee Is Due: C1 ANNUALLY ❑ PER UNIT q PER SITE -❑ EACH ❑ January 1 &Received By January 31 ❑ July 7 S ReceiveRd MITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED. AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by - .Date Receipt.No. - ..- Permit No. - -Iss ante ate '^Mailed Delivered <br /> Received <br /> ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON,CA 95201 <br />