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r Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> OR ONCE USE: APPLICATION _ <br /> (For Non-Transferable, Revocable,Suspendable) pLJMP&WELL <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> t <br /> f (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application 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 San Joaquin County Or 'Pti ce N 62 and the r les and regulations of the San J aquin Local Health District. <br /> Exact Site Address 14 2City/Town <br /> Owner's Name z Phone <br /> 1010,/ <br /> AddressBusiness Phone� City L <br /> j Contractor's Name License#�1 � <br /> j <br /> I. Contractor's Address _ 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 L3 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATICOP <br /> PUMP REPAIR❑ <br /> jREPLACEMENT <br /> F 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 <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ' ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout l <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Sur ce Seal Installed B <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump oe H.P. <br /> PUMP REPLACEMENT: � State Work Done r <br /> PUMP REPAIR: State Work Done �. <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I Describe Material and Procedure <br /> I 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 manner as to become subject to workman's compensation laws of California." <br /> 1 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 /> ill call for a Grout In pection prior to grouting and a final inspection <br /> Af <br /> r Signed X Title: Date: r <br /> (Draw Plat Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY �. <br /> PHASE I r '-3 <br /> Appiication Accepted By Date <br /> Additional Comments: &V% <br /> Phase II Grout Inspection Phase III Final I spection <br /> Date Inspection By C • D to Z 9 <br /> Inspection By <br /> 04 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH EI January 1 &Receive By January 31 ❑ July 1 &Received 8y July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> i, DATE DATE REMITTED AMOUNT <br /> I FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> S — � <br /> Received by Date Receipt No ermit No Issuance Date Mailed Delivered <br /> k. APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />