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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TheApplication. \ <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Health District fora permitto construct and/or install thework herein described.This application is <br /> made in compliance wit n Joaq i�.Goun n e o.i 2 the ru{ nd regulations of the S qu' Local Health District. <br /> Cit /Town 0 G C1 �\ <br /> Exact Site Address � City <br /> /Town <br /> Name Phone <br /> Address4,1 — <br /> City— <br /> Contractor's <br /> City <br /> Contractor's Namefr seBusiness Phone / <br /> Contractor's Address `� Emergency PhonO CA-� O 91/ 6397 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes—;<f No <br /> TYPE OF WORK (CHECK): NEW WELL I-f DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <N Sewer Lines Pit Privy <br /> Sewage Disposal F�Icl ST.J /-70-- Cesspool/See page Pit <br /> Property Line/6 Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation. <br /> i� <br /> O MESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 1 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout <br /> ❑ CATHODIC PROTECTION 0'ROTARY Type of Grout +' <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal installed By: , S_f&C -. <br /> PUMP INSTALLATION: Contractor N <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done - <br /> DESTRUCTION 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 <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 sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall empl ons subject to workman's compensation laws of California." <br /> _) <br /> sG <br /> will call for a rou Ins c 'on rior gr ling and a final inspection. <br /> Sign_ed X Title: , Date_ <br /> /3 <br /> (Draw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted Date <br /> Additional Comments: <br /> P e II G ut Inspection �tse III Inal Inspe tion <br /> t. <br /> Inspection f3 lomat r 7 Inspection Date 'I i <br /> Fee Is Due: ❑ A NUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received.By-July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ` <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 3 -72"l-ftS AIX <br /> Recelvedl6y Dat Receipt No. Permit No Is ance Clate Mailed DelivereeK <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />