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Applications Will Be Processed When Submitted Properly Comple eySllreto3`ign Tffe fiWli ' <br /> FOR OFIFICE USE: APPLICATION }-�- ,. <br /> (For Non-Transferable, Revocable,SuspendabI4 EP 2 5 1979 <br /> _ <br /> ENVIRONMENTALAL HEALTH PE SUMP&WELL <br /> JOAQUfN LOCAL <br /> (POMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRIC� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereln escribed.Thisapplicationis <br /> made in compliance with SaLLJ222r Count Ordi a 18 nd the rules and a ulaU s of the Sa oa yin Lo t District. <br /> Exact Site Address "'ir' ��� �1 0 �p A7 Town 70 <br /> Owner's Name ! �i� I4 l <br /> Phone <br /> Address r7, City _ <br /> Contractor's Name lv / M� _ License#✓ 3?3 Business Phone <br /> g T <br /> Contractor's Address '14 r ` 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❑ T ' <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR L <br /> t 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 /> r ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing �w <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 'I <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: 11 State Work Done <br /> t <br /> PUMP REPAIR: R-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 /> r <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed ageni'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 for which this <br /> permit is i , I shall emp ersons subject to workman's compensation laws of California." <br /> I r G ut Insp ion rior to grouting and a final ins ' <br /> Signed X Title: Dale: <br /> (Draw Plot Plan on Reverse Side) ----°- <br /> FOR EPARTMENT USE ONLY <br /> PHASE t <br /> Application Accepted ByZ�" Date <br /> t Additional Comments: <br /> Phase Grout Inspection Phase.111 Final Inspection <br /> Inspection By Date Inspection By Date AQ~3o-Ick <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT KPFR SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 77 TI-1 ?1 <br /> Received by Date Receipt No - Permit No. Issuance D to Maslecl s - Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: - -ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 <br />