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- Applications Will Be Processed When Submitted Properly � s <br /> APPLICATION <br /> FOR aFFice tsE: �4 �1 UMP&WELL <br /> _ (For Non-Transferable, Revocable, Suspnl� , <br /> ENVIRONMENTAL HEAL EtT �g�0 <br /> WATER QUALITY �� <br /> (COMPLETE IN TRIPLICATE) t t t <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or Install the workaIT, i�+�-ea4 Health Distrribed.This ict, Is <br /> made in compliance with San Joaquin County Ordina,)ce No. 1862 and the rules an gulati a. eJb t <br /> PaR <br /> Exact Site Address <br /> hone <br /> Owner's Name City <br /> �/ <br /> Address License#I —Z1_ Business Phone ' ` � C> <br /> Contractor's Name Emergency Phone/ <br /> Contractor's Address t/ 1 <br /> 4 No <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ElRECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION El ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT Pit Privy <br /> Sewer Lines — <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line - Private Domestic Well <br /> INTENDED USE t TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation Citi <br /> ❑ INDUSTRIAL Dia. of Well Casing (� <br /> 13DOMESTIC/PRIVATE 13 DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> I ❑�E70M1STIC/PUBLIC C] GRAVEL PACK Depth of Grout Seal <br /> I I� IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION <br /> t ❑ <br /> ❑ DISPOSAL . OTHER Other Information <br /> . Surface Seal Installed By: <br /> 11 GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H P <br /> Type of Pump <br /> j PUMP REPLACEMENT: ❑yState Work Done <br /> PUMP REPAIR: State Work Done <br /> tApproximate Depth _ <br /> DESTRUCTION OF WELL: Well Diameter <br /> r Describe Material and Procedure <br /> 3 <br /> { certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby ^ <br /> rules and regulations of the San Joaquin Local Health District. <br /> rtifies the following:"I certify that in the performance of the work for which this per <br /> Home owner or licensed agent's signature cemit <br /> ordinances, state laws, and <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> l g'. <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 /> 1 will call for a Grout Inspection prior to grouting and a final inspection. Date: !/' d <br /> I Title: IiI <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> PHASE i �6^ 1 4 n nom„ Date ' <br /> >,XJ�YfU v'�""" <br /> Application Accepted By. <br /> Additional Comments: hase III Final Ins etion <br /> Phase II Grout Inspection rate <br /> Inspection By <br /> Date Inspection By. <br /> ' ❑ PER SITE El EACH ❑ January 1 Received By January� July 1 8 Received By July 31 <br /> Fee 1s Due: C3 ANNUALLY' ❑ PER UNIT REMIT <br /> p KILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> L <br /> FEE <br /> IG. <br /> LESS Ly r, P 4f19-S1 <br /> PRORATION E �i�- d i <br /> PLUS ML+U y��Y41(.r. <br /> PENALTY �y fI Cory<r�L o - <br /> I OTHER -017 PQ �l.' (� f7 A 4z/9 <br /> S OTHER ` j L._lq-1� <br /> nrd e t4AC 6f o <br /> (( 7 1l. 1�(.� $s <br /> _ pINpI+ �y/ �{/ Permit No. — Iss ance D to Mailed Delivered <br /> Received <br /> CANT=RETURN-ALL GOPIES TO:.7�NVIRONMENYAL HE THP ENVICES 1601 E.HAZELTON AVE.,P.O.Box'2009 STOCKTON,CA 95201 <br />