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Applications Will Be Processed When SubmittedProperlyGomPieiecs. o� �� � •� <br /> APPLICATION <br /> FOR OFFICE USE: 74-1d <br /> (For Non-Tr9nsferaENe, Revocable,Suspendable) PLlMp&WELL <br /> Et ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY 0f7-(7V^(0 <br /> (COMPLETE IN TRIPLICATE)'^� S3O- � +���� <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install the work herein described.This application is <br /> made in compliance vyi Sa Joaquin ou ty Ordi ce N�. 1862 and the r les d re lati y�f the San Joaquin ocal Health District. <br /> Exact Site Address <br /> Phone <br /> Owner's Name O City <br /> Address <br /> /Ll License Business Phone <br /> Contractor's Name ��4N�/L� �/�� <br /> C�• S �ZL 9d Emergency Phone <br /> Contractor's Address < a u ' No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL;I. DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ElOTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ C <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ?.��— Sewer Lines �-� Pit Privy Cesspool oal/Seepage Pit Other <br /> Sewage Disposal Field p � _ <br /> Property Line11—_Private Domestic Well s — - <br /> 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 /> 13 DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �- <br /> ❑ DISPOSAL 11 OTHER <br /> Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: fi <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H P. L <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 /> ordinances, stato 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 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 forwhich this <br /> permit is issued, I shall employ pers subject to workman's compensation laws of California." <br /> I will or a Gro n ctio outing and a final inspection. <br /> Title: ! Date: <br /> Signed X <br /> (Draw Plot Plan on Reverse S e) <br /> FOR DEPARTMENT USE ONLY �+ <br /> PHASE I Date -3 7 0 <br /> Application Accepted By <br /> Additional Comments: �0"ate <br /> ction <br /> Phase II Grout inspection �, /Inspection By <br /> Date � Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> iso—l3 •� <br /> Receipt No. Permit No. Issuance Date Mailed Delivered <br /> L HEALTH PERMIT/SERVICES 1601 E.HA26LTON AVE.,P.O.Box 2099 STOCKTON,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTA952 <br /> Received by Dale <br />