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II f a Groutpspection prior to grouting and a final Inspection. <br />4 Signed X Date: Title: P‘4.1%4.44„„.... <br />Date 71'0k <br />PHASE I <br />Application Accepted By <br />Additional Comments: <br />WO, <br />spection By Inspection By <br />election crf zs 90 <br />Date <br />ut Inspection \ Br) <br /> Date <br />Fee Is Due: 0 ANNUALLY CI PER UNIT 0 PER SITE 0 EACH 0 Jamie 1 $ R eived B January 31 JuN 1 <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />_ <br />APPLICATION <br />(For Non-Transferable, Revocable, Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />COMPLETE IN TRIPLICATE) WATER QUALITY <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work <br /> City/Town <br />FOR OFFI,FE USE: <br />Exact Site Address <br />PUMP & WELL <br />aunty Ordinance No. 1862 arid the District. <br />made in compliance w .th San Joaquin i rules and regulationsof the Z::,,J aquin Local Health <br />herein described. This application is <br />Sewer Lines Pit Privy <br />Cesspool/Seepage Pit Other <br />Property Line Private Domestic Well Public Domestic Well <br />TYPE OF WELL <br />CABLE TOOL <br />DRILLED <br />DRIVEN <br />GRAVEL PACK Depth of Grout Seal <br />ROTARY Type of Grout <br />OTHER Other Information <br />Surface Seal Installed By: <br />Contractor <br />TYPE OF WORK (CHECK): NEW WELL 0 DEEPEN 0 <br />WELL CHLORINATION 0 WELL ABANDONMENT 0 <br />REPLACEMENT <br />DISTANCE TO NEAREST: <br />Owner's Name <br />Address <br />Contractor's Name <br />Contractor's Address Emergency Phone <br />Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 100, No <br />Septic Tank <br />Sewage Disposal Field <br />INTENDED USE <br />ELINOUSTRIAL <br />M-DOMESTIC/PRIVATE <br />DOMESTIC/PUBLIC <br />IRRIGATION <br />CATHODIC PROTECTION <br />DISPOSAL <br />GEOPHYSICAL <br />PUMP INSTALLATION: <br />Dia. of Well Excavation <br />Dia. of Well Casing ‘\.1 Gauge of Caging Nt, <br />Type of Pump H.P. <br />State Work Done <br />State Work Done <br />Well Diameter <br />Describe Material and Procedure <br />PUMP REPLACEMENT: <br />PUMP REPAIR: <br />DESTRUCTION OF WELL: <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 />Home owner 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this <br />permit is issued, i shall employ persons subject to workman's compensation laws of California." <br />wit <br />(Draw Plot Plan on Reverse Side) <br />FOR DEPARTMENT USE ONLY <br />BASE EXPLANATION BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE 413 t--6 CA.rn 4 Lj-,S <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />"2, r2 <br />Received by Date Receipt No Perrnit No <br /> APPLICANT—RETUFIN AU. COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />C31 t <br />Issuance Date Mailed livered <br />1601 E. HAZELTON AVE., P.O. Box 2009 STOCKTON, CA 95201 <br /> License #318%/7 t Business Phone_83'4 .2421 54 <br /> Phone <br />City a-44,..$11......""' <br />RECONDITION 0 DESTRUCTION 0 <br />OTHER 0 PUMP INSTALLATION PUMPREPAIRD <br />4 <br />Approximate Depth