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FOR OFFICE USE: APPLICATION tt, S 1 <br /> (For Non-Transferable,Revocable,5uspendable) gr WELL <br /> ENVIRONMENTAL HEALTH PERMIT C <br /> QUALITY <br /> (COMPLETE IN TRIPLICATE) WATER Q <br /> A ation is hereby made to the San Joaquin Local Health District for a permit to construct and/Or install the work herei�t}��Cii� <br /> mt n compliance with <br /> Sian/Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Lo a, ' <br /> Exact Site Address 5 ] � .s...w lit ��l�W? I„1 ' <br /> CityfTown � ' <br /> Owner's Name ✓ Phone <br /> Address City <br /> Contractor's Name Lrcense# Business Phone <br /> Contractor's Address Pe'/u/ f9-27 (4,44 1 CqK, _ Emergency Phone <br /> Is Certificate of Workman's Compensation insurance on Fite 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 <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 Dia.of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia_of Well Casing <br /> DOMESTIC/PUBLIC 0 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0 GRAVEL PACK Depth of Grout Seal <br /> © CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> © DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seat Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ©$tate Work Dom <br /> PUMP REPAIR: State Work Done (" <br /> DUCTION 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 J <br /> ordinances,state laws, and rules and regulations of the San Joaquin Local Health District. t_- <br /> Homeowner <br /> domeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." <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 /> I will call for a Grout Inspection prior to grouting and a final inspection. n <br /> Signed 4 J PL11, Title: <br /> (Draw Plot Plan on Reverse Side) IV <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 �] <br /> Application Accepted By ! Dates _ 1 <br /> Additional Comments: -- <br /> Phase 11 Grout Irlillorra � .`�n F J t ection <br /> Inspection By bate Inspection S. " ' Date 't <br /> w <br /> Fee IS Dire:0 ANNUALLY ❑ PER UNIT ©-PER siTE ❑ EACH.. ❑ January Received 8y January 31 ❑ Juty i 8 Received By July 3? <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION DALE DATE REMITTED AMOUNT DUE CHEGKEO <br /> AMOUNT <br /> FEE t .-- <br /> LESS <br /> PRORATION <br /> ,PLUS <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> ,Y t <br /> Received by Date Receipt No. Permit No. <br /> iss nce ate 5 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT1SERVICES IGH E.HAZEL.TON AVE.,P.O.Box MN STOCKTON,CA 95201 <br />