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ApplicationsWill Be Processed When Submitted Properlycompiexea.prq�TV,varvir' <br /> FOR OFFICE USE: / ; I APPLICATION <br /> {For Non-Transferable, Revocable,Su ale) ` �1 v �,'�p&WELL <br /> ENVIRONMENTAL HEALTH P <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to theSainJoaquinLocalHealthDistrictforapermittoconstructand/orin� rkherein described.This application is , <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of th San Joaquin Local Health District. <br /> , <br /> Exact Site Address City/Town�.30e� I° ��at� <br /> �� Phone Q —�© v <br /> Owner's Name <br /> Address e city ���� <br /> 2 s License# `35�5� B sines Phone —.; <br /> Contractor's Name /Y°� <br /> Contractor's Address 0 <br /> ,$d ,3 3� Emergency Phone <br /> Is Certificate of Workman's Gompensa ion Insurance on File With SJLHD? Yes 25 _ No �[ <br /> TYPE OF WORK (CHECK): NEW WELL ElDEEPEN ❑ RECONDITION 11DESTRUCTION❑ �J <br /> i WELL CHLORINATION ❑ WELL ABANDONMENT ElOTHER 11PUMP INSTALLATION 11PUMP REPAIR <br />[ REPLACEMENTS <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> _ Property Line — ' Private Dorrlestic Well' Public Domesfic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> IR DOMESTIC/PRIVATE ' i ❑ DRILLED Dia- of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 11 ROTARY Type of Grout <br /> ❑ DISPOSAL i. ❑ OTHER Other Information <br /> t ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor A <br /> ,I Type of Pum <br /> y r P. f Y <br /> PUMP REPLACEMENT: State Work Done � � <br /> I PUMP REPAIR: ❑ State Work.Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure A <br /> I hereby certify that 1'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 /> Contractor's hiring orisub-contracting signature certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shaill employ persons subject to workman's compensation laws of California." <br /> li <br /> I will call for a Grout `Inspection prior to grouting and a final inspectionep. <br /> Signed X <br /> iP _ Title: Date: <br /> (Draw}Plot Plan on Reve a Side} <br /> j FOR DEPARTMENT USE ONLY y j <br /> PHASE I JI <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phse II Grout Inspection P III Fina Inspection <br /> Inspection By Date Inspection By A/ Date <br /> Fee Is Due: Cl ANNUALLY �i� ❑ PER UNIT PER SITE El EACH - El January 1 8 Received By January 31 .El July 1 8 Received By July 31 <br /> REMST <br /> III - BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS. <br /> PRORAT4ON I - <br /> i PLUS <br /> PENALTY .I <br /> OTHER <br /> I; <br /> 'OTHER <br /> Received{ -by Date Receipt No. Permit No. lssu r.D to Mailed Delivered <br /> I APPLICANT--RETURN ALL COPIES TO: ENWRONMENTAL HEALTH PERMITlSERYICES 1601 E.HAZELTON AVE,,P.D.Box 2009 STOCKTON,CA 95201 <br /> �'Q > <br />