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Applications Will Processed When Submitted Properly Completed. Be $Sf T.WStgn"riseAppucanon. I I ' f <br /> FOR OFFICE USE APPLICATION �� j� i <br /> (For Non-Transferable, Revocable, Suspendable) MAR 16 1g$lnnp&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SAN J SIN'Rei girl �.rn <br /> zy i_ <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) HT�-j 7iS�� i' <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 Co my Ordi an a No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address ". 33 _ __ City/Town <br /> Owner's Name Phone V r <br /> City <br /> Address <br /> { <br /> Contractor's Name License#1a�� Business Phonerf'�9 8 f <br /> Contractor's Address rG, Y Emergency Phone <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD3 Yes No <br /> TYPE OF WORK (CHI=CK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ,a PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ <br /> r' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other t <br /> Property Line Private Domestic Well Public Domestic Well 4 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> f. ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ( ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> L ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout_ <br /> 4 ❑ DISPOSAL ❑ OTHER Other Information <br /> t ❑ GEOPHYSICAL .�1 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> j� Type of Pump *�� H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done Id <br /> ni <br /> PUMP REPAIR: 19 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 /> 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. <br /> iContractor'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 will call for a Grout Inspec ' prior to grouting and a final inspeii <br /> Signed X �.st"rt �` ''� Title: _� �-�-J gate: <br /> (Draw Plot Plan on Reverse Side) �c�r <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Dated I8 81 <br /> Application Accepted By <br /> Additional Comments: <br /> 04= <br /> pection P se III Final Inspection <br /> Inspection By Date Inspection ByDate <br /> J_ , 4*5I <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 1 ❑ July l &ReceivedREMITuly 31 r <br /> J <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> O y <br /> FEE ��✓ '��� . <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY F <br /> OTHER r* <br /> OTHER <br /> Ib bS � <br /> 1� 1�31 <br /> "Issuance Date Mailed Delivered <br /> Received by ate Receipt No .-Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 952017(0' <br />