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ti Applications Will Be Processed.When Submitted Properly,Completed. Be Sur^OR FICE!USE: In. <br /> ig �F7 I tifn. LAPPLICATIQN <br /> 4^4,(For Non-Transferable, Revocable, Suspendable) (�J( <br /> � <br /> —� <br /> O C n 5 <br /> EN IRONMENTAL HEALTH PERMIT t� P� � WELL � <br /> (COMPLETE IN TRIPLICAE) WATER IIALITY SAN 00 4'QU(N ILOCAL -5: <br /> dApp <br /> Application.ishereby made tothe San Joaquin Local Health District for apermit toconstruct and/or instafl the jJKI I Tib 17Tt3e .l Tsa application is <br /> ErQI ' C <br /> made in compliance with an Joaquin County Ordinance No, 1862 d the rules and regulations of the SaJ a uin focal Health District. <br /> . 1�1�' \/4 ivI i9 <br /> Exact Site Address Lc City/Town 440,&-d <br /> Owner's Name R l Phone 3uo 3 <br /> Address l City 4s,G13/a� <br /> Contractor's Name r , o License#oG X11 <br /> Contractor's Address ;- Business Phone 83�_'� <br /> 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 LJ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP'REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> p 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 /> ❑, _ IN STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> "DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing I <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> ❑ DISPOSAL Type of Grout _ <br /> ❑ OTHER Other Information <br /> GEOPHYSICAL <br /> ❑ Surface Seal Installed By: <br /> PUMP INSTALLATION; Contractor 1 <br /> Type of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: R1 State Work Done 311 . <br /> DESTRUCTION OF WELL: ! <br /> Wel! 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of 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 call for a Grout Inspectio nor to routing and a final inspectio I <br /> Signed X J <br /> is 11� <br /> Title: Date: !� <br /> (Draw Plot Plan on Reverse Side <br /> i <br /> OR D ARTMEN USE ONLY <br /> PHASEI r <br /> Application Accepted By Date �'� �J <br /> Additional Comments: <br /> Phase H Grout Inspection Pqbsre III Final fnspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 I <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> gg DATE DATE HEMiTTED AMOUNT DUE CHECKED <br /> FEE �'-Y' AMOUNT <br /> LESS ` <br /> 11 s r <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed i <br /> Delivered <br />� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />�, � .. I - � � .1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOk_cn Qsim <br />