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Applications Will Be Processed When Submitted Properly CompleteyeSt1 7e p►PPnca,� <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspe�e} SE� PlW&WELL <br /> ENVIRONMENTAL-HEALTH PERMIT niN LOCM. <br /> WATER QUALITY ��' �`r `fR4CT <br /> t (COMPLETE IN TRIPLICATE) `" H �re <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or i nslaift t�ork�heuein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> �1 . Patrick Rd. City own Exact Site'Address V <br /> �.�. Phone: e <br /> 61 57, <br /> Owner's Name City <br /> AddresskAel" �� Business Phonel" <br /> Contractor's Name i License#�V. - �$ } <br /> ,. Emergency Phone," <br /> N <br /> Contractor's Address r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> J a <br /> TYPE OF WORK (CHECK)` NEW WELIL❑ DEEPEN ❑. RECONDITION❑ ' DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑. PUMP INSTALLATION -PUMP REPAIR❑ <br /> REPLACEMENT❑ I. Pit'Privy <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> Cesspool/Seepage Pit Other <br /> - Sewage Disposal Field t <br /> Property Line Private Domestic Well Public Domestic Well <br /> 4 ` TYPE OF WELL q <br /> it INTENDED USE <br /> 11 INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> f• j i <br /> 11 DOMESTIC/PRIVATE 11DRILLED Dia. of Well Casing f <br /> © DOMESTIC/PUBLIC �.. ❑"DRIVEN Gauge of Casing <br /> ❑ IRRIGATION <br /> ❑ GRAVEL PACK Depth of Grout Seal I <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout )' ; <br /> l ❑ OTHER Other Information_ t <br /> 11DISPOSAL <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Moorman r s Water <br /> ble H.P. <br /> Type of Pump <br /> with new <br /> PUMP REPLACEMENT: State Work Dorie t , <br /> PUMP REPAIR- ❑ State Work Done <br /> Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure 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 /> Home 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, 1 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 persons subject to workman's compensation laws of California." <br /> wi call for a Grout Inspection prior to-grouting-and a.tina! inspection...,-;r..«„ <br /> r Title: f IPS/'/i�. 7;kt Date: " r <br /> .-Signed X d` <br /> a (Draw Plot Plan on Reverse Side) ; } <br /> FOR DEPARTMENT USEIp0��,NL;Y_ <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: I <br /> Phase II Grout Inspection PK ase I Final Inspection <br /> } pp RR Inspection By. 3 Date — <br /> Inspection Bye, 1 Date <br /> Fee'Is Due: ❑- ANNUALLY ❑ PER UNIT" ❑ PER SITEACH El January 1-&Received By January 31y0 July 1 &ReceivedJuly 31 <br /> R EMIT <br /> - gq$@ EXPLANATION W - BILLING REMITTANCE, $ AMOUNT DUE .� CHECKED <br /> DATE DATE REMITTED i AMOUNT <br /> � 8 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS ` ,t <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> Date - .'Receipt No. - - ._ _ Permit-No- __ Issuance Date Mailed Delivered _ . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br /> 1601 E.HA2£LTON AVE.,P.O.Box 2909 STOCKTON,CA 95261 <br />