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Applications Will=BWProcessed When Submitted Properly Completed. AgoreTo Sign The Ap licatioULJJ <br /> FOR OFFICE USE: i' APPLICATION MAR 16 1981 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIAN 10AQIJ'!N LMNE&WELL <br /> (COMPLETE iN TRIPLICATE): WATER QUALITY HEALTH DISTRICT <br /> r <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described,This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Loc Health District. <br /> Exact Site Address mt 7`G City/Town <br /> Owner's Name Phone <br /> Address /G/0� 2 ,�r� _ City <br /> Contractor's Name5 1.CY ilt�°�. License#2 Business Phone 0 <br /> Contractor's Address Emergency Phone ley-W <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 ❑ is 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 ❑ 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 />[j ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> n <br /> Type of Pump H.P. <br /> k PUMP REPLACEMENT: ❑ State Work Done a <br /> PUMP REPAIR: ®'Slate Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> II Describe Material and Procedure <br /> i <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 /> 9 <br /> Homeowner or licensed agent's signature cerlifies'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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Insp tion prior to grouting and a final inspection. <br /> Signed Xk� �o � Title: �� �C =_ - Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE { <br /> Application Accepted By Date �t <br /> Additional Comments: <br /> Phase II Grout Inspection a III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑-EACH ❑ January 1 &Received By Janua- ❑ July 1 &Received By July 31 <br /> 1 REMIT � <br /> BASE .EXPLANATION - BILLING REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE L1 S. _ dy q <br /> LESS �Z <br /> PRORATION <I <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> t <br /> OTHER <br /> Received by Date Receipt No. z Permit No. Issuance Dataiied Delivered <br /> .�` APPLICANT=RETURN�ALL COPIES TO: ..ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20_ 09�STOCKTON,CA 9520A01 <br />