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Applications Will Be Processed When Submitted Properly Completed.Be.Bufie.T kn_The A p 1 tion. <br /> FOR OFFICE USE: APPLICATIONI� f�- {_ 1 I,, 1i L`+I <br /> s <br /> (For Non-Transferable, Revocable, en e) <br /> ��� i <br /> ENVIRONMENTAL HEALTW-'61` I 1981 MP&WELL <br /> ,.�7 L 17 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �y' <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct a�*N install fliN_ �k "Ar-Ascribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1662 and the rules and regulatpi—,[Qu&� ,� G 4'OPfo al Health District. <br /> Exact Site Address /g 3 City/Town . OU 3 <br /> 7,? -AOwner's Name v� �f Phone -/',7,?— <br /> Address <br /> ddress rT 4.��'y;� city .� <br /> Contractor's Name License#/(o Business Pho11e <br /> Contractor's Address �aT� � 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❑ i <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ {11 <br /> REPLACEMENT I!�' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy V + <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 /> [],GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. / <br /> PUMP REPLACEMENT:. Er State Work Done --a--.� �� <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 UJ <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:1 certify that in the performance of the work for which this permit V <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 ca r a Grout I ion prior to grou ' g and a final inspection. / <br /> Signed X Date: <br /> (Draw Plot Ian on Reverse lde) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ALy c n�x��1 q )�0 o� <br /> Application Accepted By Vn DateO <br /> Additional Comments: <br /> Phase II Grout Inspection J14ase III Final inspection <br /> Inspection By Date Inspection By bate k <br /> 7 , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive Ry January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> 00 <br /> FEE L+5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 1' <br /> /�] LS- <br /> I <br /> Received by Date Receipt No. Permit No. ssuancb Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />