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J FOR D PARTM T USE ONLY <br />RASE <br />PHASE I <br />Application Accepted By <br />Additional Comments: <br />eceived By July 31 <br />1 Si I c <br />BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED i <br />V <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />i <br />i <br />I <br />70i-1 171-6 <br />Received by Date Receipt No. Permit No. issuance Date Mai‘ed Delivered <br /> APPLICANTRETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERIIMT/SERVICES 1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON A 55201 <br />Date <br />e III Final Inspection <br />0 July 1 & Received By January 31 <br />Fee Is Due: 0 ANNUALLY <br />EXPLANATION <br />OTHER <br /> Inspection By <br />Phase II Grout Inspection <br />Inspection By Date <br />> <br />0 PER UNIT <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />4 Contractor <br />Type of Pump <br />Approximate Depth <br />State Work Done <br />State Work Done 1 1 <br />Well Diameter <br />Describe Material and Procedure <br />«0— (0 <br />(COMPLETE IN TRIPLICATE) tiq WATER QUALITY <br />Te rules arl regulations of the San Joaquin Local Health A plication is hereby made to the San Joaquin Local Health District for a permi t to construct and/or install thework herein described. This application • t <br />made in compliance with San Joa in County Ordinance No. 1 <br />Exact Site Address <br />Owner's Name <br />Address t-4-3 <br />INTENDED USE <br />INDUSTRIAL <br />APMESTIC/PRIVATE <br />DOMESTIC/PUBLIC <br />IRRIGATION <br />o CATHODIC PROTECTION \ „joilkkE 0EROTARY <br />bkSPOSAL <br />0 GEOPHYSICAL <br />1 <br />Is Certificate of Workman's <br />TYPE OF WORK (CHECK): <br />WELL CHLORINATION 0 <br />REPLACEMENT El <br />DISTANCE TO NEAREST: <br />PUMP INSTALLATION1 <br />PUMP REPLACEMENT:. <br />PUMP REPAIR: <br />DESTRUCTION OF WELL: <br />1 I hereby certify that I have prepared this application and that the work will be done in accordan.be with San Joaquin County <br />t <br />ordinalYC'esT-state laws, and rules and regulations of the San Joaquin Local Health District. <br />Homipwner 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 />,,. <br />. <br />ConTirgor's <br />t,hlring or sub-contracting signature certifies the following: "I <br />certify that in the performance of the work for which this <br />is issNed, I shall employ persons subject to workman's compensation law.; of California." <br />i ' Grout Ins ectlon prior to grouting and a final inspection. <br />Title; <br />'Sig <br />Applications Will Be Processed When Submitted Properly compieteu. <br />APPLICATION <br />(Fot Non-Transferable, Revocable, Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />Compensation Insurance on File th SJLHD? Yes No 1210 i 411/6P-r- aLtjtel ____ Emergency Phone <br />NEW WEIL 0 DEEPEN 0 RECONDITION 0 DESTRUCTION!: <br />WELL ABANDONMENT 0 OTHER 0 PUMP INSTALLATION 04, <br />0e/A /fri"4 <br />ZCW4j) <br />ii <br />Septic Tank .t Sewer' Li ries <br />Sewage Disposal:Field Cesspool/Seepage Pit 7,, A <br />Property Line Private Domestic Well <br />TYPE OF WELL <br />CABLEIN51.4 <br />DRILLED 4/ <br />DRIVEN <br />GRAVEL PACK <br />(Draw Plot Plan on Reverse Side) <br />0 ef City/Toy <br />one o <br /> City <br />License #3.39 -7 _ Business Phone <br />' L1 1 Dia. of Well Excavation ) <br />Dia. of Well Casing <br />Gauge of Casing b2 <br />Depth of Grout Seal <br />Public Domestic-Well <br />Y <br />PUMP REPAIR!: <br />Other <br />PUMP &WELL <br />Date: le)-2-SC <br />- <br />Contractor's Name <br />Contractor's Address <br />FOR OFFICE USE: <br />Type of Grout <br />ther-InfOrMati on. — <br />Surface Seal Installed By: 1. <br />b -