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I ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. -,- <br /> FOR OFFICE USE: APPLICAVONst' <br /> (For Non-Transferable, Revocable, Suspendable)=- <br /> ENVIRONMENTAL HEALTH PERMIT P MP((S,WELL <br /> {COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in stall the work herein described.This a pplication is <br /> made in compliance with San Joaquin Co ntY Ordinance o. 1862 and the rules and regulations of the San Joaquin L cal Health District. <br /> Exact Site Address s City/Town <br /> Owner's Name Phone <br /> Address 7� -Irl y City <br /> Contractor's Name 7—, ,ti License#m7 <br /> � _C/D/!� Business Phone <br /> Contractor's Address O 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❑ D STRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IK PUMP REPAIR <br /> REPLACEMENT❑ J <br /> 1. <br /> DISTANCE TO NEAREST: Septic Tank k <br /> P - Sewer Lines -Pit Privy = , <br /> Field <br /> Disposal Sewage Dis " <br /> g P Cesspool/Seepage I?it' Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE { TYPE OF WELL <br /> ❑ INDUSTRIAL ' ❑ CABLE TOOL <br /> �► Dia. of Well Excavation �.. <br /> ❑ DOMESTIC/PRIVATE ' ❑ DRILLED Dia. of Well Casing I <br /> ❑ DOMESTIC/PUBLIC t ❑ DRIVEN <br />` I❑ IGauge of Casing <br /> IRRIGATION , <br /> ❑ GRAVEL'PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION # ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL a ❑ OTHER <br /> Other Information <br /> ❑ GEOPHYSICAL <br /> ,Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor.T <br /> _ Type of Pump t H.P.—Z <br /> PUMP REPLACEMENT: ❑,State Work Done—�""�-�""` -- _- <br /> PUMP REPAIR: # ❑ Stat Work Done I <br /> DESTRUCTION OF WELL: # Well Dia�meter <br /> [ 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 for which this permit <br /> is issued, I shall not employ any person in such Imanner 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 /> I w' r a Grout s ction prior to grouting and a final inspection. <br /> c [� <br /> Signed X itle: �biUev Date: LJ <br /> (Draw Plot Plan on Reverse Side) — <br /> Y <br /> PHASEI R DEPARTMENT USE ONLY <br /> Application Accepted Dat <br /> Additional Comments: <br /> Phase 11 Grout Inspection P s III Fin 1 Inspection <br /> inspection By L Date. In By Date _ / 7 7 t <br /> Fee Is Due:-❑.ANNUALLY_ r ❑ PER UNIT El SITE F-1 EACH ❑ January T <br /> nuary 1 &Received By January 31 ❑ July 1 &Received B I 311 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMI <br /> DATE DATE REMITTED AMOUNT DUE CHECKED + <br /> AMOUNT <br /> FEE f <br /> LESS <br /> PRORATION 1 <br /> PLUS .. I!!. <br /> PENALTY --.- . <br /> OTHER <br /> if <br /> OTHER <br /> ,y <br /> Received by Date i Receipt No - Permito. Issu ce D e Mailed Delivered ° <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />