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, <br /> Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignThe <br /> FOR OFFIC5 USE: APPLICATION <br /> (For Non-Transferable, Revocable, Sus pendable) 1 pi&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby TRIPLICATE) <br /> madetthe San Joaquin Local Health District fora per to construct and/or install the work herein described.This application is <br /> made in compliance wlii& n oaquin Cou y_Ordinaryce No. 1862 and the rules and regulations of the San Joaquin Lo al Heakth District. <br /> Exact Site Address r r City/Town <br /> r, E Phone <br /> Owner's Name rr <br /> Address6� City <br /> Contractor's Name l- p License It ~Bush ss hone 'Z <br /> 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 X. DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br />'i WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal f=ield Cesspool/Seepage Pit Other <br /> Property Line /Z— Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation f� <br /> I�DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> 11DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing �– <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal© <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout C <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By; <br /> PUMP INSTALLATION: Contractor <br />{ Type of Pump f H.P. <br /> F PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: 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 /> i ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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." 7 <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 wio call fora t Inspectio prior to grouting and a final inspection. <br /> ' Signed X `` ./ Title: Dale: <br /> l (Draw Plot Plan on Reverse Side) <br /> s <br /> FOR DEPARTMENT USE ONLY <br /> kPHASE I Cly <br /> }Application Accepted By Date <br /> Additional Comments: . 1.1 <br /> 't Phase i Grout Inspection ase III Final Inspection <br /> Inspection By 7 4 Date ji Inspection By Date <br /> ❑ PER UNIT <br /> El SITE El EACH El January 1 8 Received By January 31 ❑ July 1 &ReceiveREMITd By uIy 31 <br /> Fee Is Due: ❑ ANNUALLY <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 111 ; �xf DATE DATE REMITTED �i AMOUNT <br /> 3 FEE V p Cl <br /> LESS / <br /> PRORATION <br /> PLUS a <br /> i t PENALTY i r <br /> ` OTHER t <br /> I OTHER - <br /> -XII /A <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> I <br /> i APPLICANT—RETURN ALL ate TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _ 1601 E.HAZELTON AVE,,P.O.Boa 2009 STOCKTON,CA 95201 <br />