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Appli nlli�(�e� rosgd1�e milted Properly Comple _ .- Sre To 9 niT,�he�pp i n. <br /> FOR"OFf10E USE: L� V PPL1bAT1 N u ��, Lo <br /> (For Non §ferable, Revocable;'S dable) pLiM ELL <br /> DEC 2 E 60NMENTAL HEALTH RMI1DEC 3 0 1981 <br /> lig{, I WATER QUALITY, „ .� , <br /> (COMPLETE IN TRIPLICATE) SAN )�j(`, ��'1 ' � r � I A.�,�... , �L (3 j - f ��2- <br /> Applicationishereby made tothe � ;gH,"JtXistrlctforapermittoconstructanrll msta1thel,vo h�rii;,described.This application is <br /> made in compliance with San Joaquin County Ordinance o.,4862 and the rules and regulatiol"6&TkLn� �ff¢q cAal Health District. <br /> Exact Site Addr ss+ J .,il ,�t�e� ��a a �r� .r /c' r��-'5.�� City/Town �E <br /> Owner's Name " ' i � � Phone <br /> Address -Q City^ <br /> Contractor's Name License•#1g,2-3�3 Business Phone' <br /> Contractor's Address p/- f 7 Emeigency Phone°' ) <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes _ No . <br /> TYPE OF WORK (CHECK): NEIN WELL❑ DEEPEN ❑ RECONDITION'❑ DESTRUCTION❑ 4— <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines, Pit Privy <br /> Sewage Disposal Field ' `-Cesspool/Seepage Pit Other ` <br /> Property Line -Private Domestic Well E'. ""Public Domestic Well Y <br /> INTENDED USE - TYPE OF WELL - <br /> ❑-INDUSTRIAL ❑ CABL:E TOOL' •" ?` Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED a Dia. of Well Casing ` <br /> ❑ ppMESTIC/PUBLIC ❑ DRIVEN y Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seale. <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ' <br /> ❑ GEOPHYSICAL Surface Seal Installed By:;- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: - ❑ Mate Work Done LL <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure d ' <br /> I hereby certify'that I have prepared this application and that the work.wijl be done in accofdance 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 /> f. <br /> Contractor's hiring or sub-contracting signature certiiies 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." ` 4 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> wi <br /> Signed X 'f keen- 7'Y- Ca it rs. f.fay Title: 227 Date:. <br /> i 4} .4,�(Draw Plot Plan on Reverse Side _ . <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ir / <br /> Application Accepted By Date "30$1 <br /> Additional Comments' i` ` -.e _ <br /> Phase II Grout Inspection w�,� _ r T- t Ph 111"Final spection <br /> Inspection By. Date Inspection By Date J <br /> Fee IS Due: ❑ ANNUALLY -❑ PER UNITS ❑ PER SITE ❑ EACH', ❑ January 1 &-Received�By January 31 July 1 &Received By July31 <br /> BILLING REMITTANCE .. $ _ ` REMIT <br /> BASE EXPLANATION AMOUNTDUE CHECKED <br /> DATE DATE REMITTED4 <br /> AMOUNT <br /> FEEG(J-Qil=r..._ U.. ��f CA-14 <br /> LESS r <br /> PRORATION <br /> -- - PLUS <br /> PENALTY - - <br /> OTHER F <br /> OTHER <br /> Obi eE <br /> Received by Date -Receipt No. Permit No.- F -- -Issualhce D to Mailed Delivered s <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA.95201 <br />