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FOR OFFICE USE: APPLICATION / <br /> (melon-Transferable,Revocable, Suspendable) YP&WELL <br /> ENVIRONMENTAL HEALTA - <br /> PE�R11 19,3 1"6 <br /> 11 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to cons6kfinclVoriostall[t(e(v@lr`Nlrein described.This application is <br /> made in compliance with San Joa um County^OrdinanFa No. 1862 and the rules and rdpHatiorisivf fV eSar'i� oayuin Local Health District. <br /> Exact Site Address � �pp 3 � �1- ' City/Town `�— <br /> Owner's Name 24 A.,4 f, -,f- C"/a,",& ���— Phone me Z-Z <br /> Address 4=SA l-, City n <br /> Contractor's Name .c-� License#/-(.-2=3-7-3— Business Phone <br /> �p_� r fe-G-� Emergency Phone BGG^`?KP old <br /> Contractor's Address J <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ ._C. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Donlastic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL ' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia.of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN _ Gauge of Casing <br /> la <br /> 'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL - Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor__�g -� f'-'t°�✓ +*� <br /> Type of PumH.P. <br /> PUMP REPLACEMENT: 113 State Work Done <br /> PUMP REPAIR: tate Work Done <br /> DESTRUCTION OF WELL: - Well Diameter - _ Approxim a Depth - <br /> Describe Material and Procedure Q� <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 /> 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 /> Contractor's hiring or subcontracting 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 yvl{I call I r a Groul eetlon prior t grouting and a final inspe`c{�ojn. <br /> Signed X �!)(/L-� o oZTitle: � 5A� Dale: <br /> (Draw Plot plan on Reverse Eike) <br /> I&. DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Ph 11 Grout Inspection P e III Final Inspection gg <br /> Inspection By _P" Date I Inspection By Date SL! <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE :❑ EACH ❑ January 1 a Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE .�� <br /> LESS <br /> Tk- <br /> PRORATION <br /> PLUS <br /> PENALTY j <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss ante Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Soca 2009 STOCKTON,CA 95201 <br />