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c t„ ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) 467-3 <br /> f / P &WELL <br /> t <br /> ENVIRONMENTAL HEALTH PERMIT UMP O <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> APPI ication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work.herein described.This application is <br /> ' made in compliance with�SanJoaquin County Ordina ce No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town <br /> r <br /> Owner's Name c D I f <br /> 77 ® <br /> Address Phone <br /> _ cam_/ • r City <br /> Contractor's Name ; License Business Phone S <br /> Contractor's Address 0 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 13 I <br /> 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 /> _❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 <br /> E ❑ DOMESTIC/PUBLIC ❑ <br /> DRIVEN Gauge of Casing <br />` ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> 13DISPOSAL ❑ OTHER Other Information <br /> 1:1 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> C <br /> Type of Pump H.P. <br /> E PUMP REPLACEMENT: ❑ State Work Done S <br /> PUMP REPAIR: I❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth r <br /> Describe Material and Procedure <br /> I hereby certify that] have pca <br /> 1. repared this applition and that the work will be done in accordance with San Joaquin County <br /> ordinances,.statel,16ws; and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:A certify that in the performance of the work for which this permit f <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 subcontracting signature certifies the following:"I certify that m the performance of the work forwhich this <br /> "permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi a Grout Ins ection prior to grouting and a final inspection. t <br /> j - <br /> Signe Title: I Date: <br /> (Draw Plot Plan on Reverse Si <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I yam" <br /> Application Accepted By, _ 1 Date Z 8O <br /> Additional Comments: <br /> r <br /> Phase If Grout Inspection Phase II Fina Inspection <br /> Inspection By —pate Inspection By iC. Date <br /> Fee IS Due: ❑ ANNURLLY Y❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January S &Received By January 31 ❑ July 1 &Received By July 31. <br /> BILLING REMITTANCE REMIT µ <br /> BASE EXPLANATION $4 AMOUNT DUE <br /> DATE DATE ;RlTED CHECKED <br /> AMOUNT <br /> FEE �5 �` 1 Q� <br /> LE55 <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> OTHER er <br /> I <br /> OTHER ' <br /> it <br /> Received by Date Receipt No. Per <br /> No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTOl C' 95201 , <br /> t i <br />