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pp(cationsWill BeProcessed When Submitted Properly Completed.Be Sure To,.%gn-The A is ' <br /> { ` FOR OFFICE USE: APPLICATION <br /> l <br /> I� (For Non-Transferable, Revocable, SuspaE <br /> ENVIRONMENTAL HEALTH PT S�� 1 �g8�p &WELL <br /> (COMPLETE IN TRIPLICATE) '�� WATER QUALITY <br /> Application is hereby made to the San Joaquin LocalHealth District fora permit to construct and/or tall tl ew Qrkt her*iri(fa-eA ed.This application is <br /> made in compliancepith San Joaquin County Ordinance No. 1862 and the rules and re ulation ti# �.k <br /> Exact Site Address Y 1Yt` r g � Td�L+iealth District.Sf! City/ linUS l <br /> { Owner's Name /_0 �23 <br /> 3 <br /> Address Phone <br /> Ie <br /> Contractor's Name i ,� �Q City <br /> F 2 ,License#� Business Phone .. 3 — <br /> Contractor's Address -L Emergency Phone Q <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1I ` <br /> TYPE OF WORK (CHECK); NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER C1 PUMP INSTALLATION ® PUMP REPAIR <br /> REPLACEMENT❑ :I„ <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 <br /> ❑ DOMESTIC/PRIVATE � ! Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC i ❑ DRIVENGj <br /> auge of Casing <br /> RRIGATION 1 ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION r ❑ ROTARY I <br /> I Type of Grout <br /> 11DISPOSAL k ;.=' ❑ OTHER <br /> Other Information <br /> ❑ GEOPHYSICAL r R <br /> i Surface Seal Installed By: <br /> I <br /> PUMP INSTALLATION: Contractor ` 1 <br /> ' i Type of Pump I <br /> H.P. I <br /> PUMP'REPLACEMENT:x, _ ❑ State Work Done 1 <br /> PUMP REPAIR: <br /> El State Work bone I' � <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> ameter <br /> I 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' <br /> , and rules and regulations of the San Joaquin Local Health District. <br /> r , <br /> - <br /> Home owner or licenseld'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 6ploy any-person in sucmanner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring olisub•'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 will call to a outipection prior to grouting`and a final inspection. <br /> Signed X Title: <br /> Date: <br /> it (Draw lot Plan on Reverse Side) <br /> T� _ T4- FOR DEPARTMENT USE ONLY_ <br /> PHASE ! - .. r. <br /> Application Accepted By ` 0�aD <br /> Additional Comments: I, Date <br /> Phase II Grout Inspection <br /> I� <br /> Phase III Final Inspection <br /> Inspection By Date inspection By <br /> " � € Date 1 <br /> Fee Is•Due: ❑ ANNUALLY ❑� PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION EXPLANATION BILLING REMITTANCE $ REMIT <br /> i DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT F <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY , � T <br /> OTHER <br /> OTHER <br /> Received by _ DaF - t t <br /> Receipt No. - Permit No. ssuan a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZEL TON AVE.,P.O.Box 2009 �STOCi(TON,CA 95201 <br />