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Applications Will Be Process When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 'FOR o4,ICE USE: ���� APPLICATION J % <br /> COQ- (For Non-Transferable, Revocable, Suspendable) <br /> (�NVII+RO/N�MEN AL►HEALTH PERMIT <br /> WPS I'&WELL/ / 5• �[ A QUALITY <br /> i <br /> (COMPLETE IN TRIPLICATE e �� <br /> Application made to the San JoaquinLocalHealthDistrictforapermittoconstructand/or install the work herein described.This application is -� ? <br /> pp Y <br /> made in compliance with San Joa uin County rdinarlce No. 1862 nd the rules and regulations of the San Joa in Local Health District. j <br /> 4 <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> k City <br /> Address ! <br /> Contractor's Name Lltr License#_ 190 S 7_1JBusiness Phone4! 416 <br /> Contractor's Address Emergency Phone I <br /> Is Certificate of Workman's Compensation Insurance on File W' h SJLHD? Yes k 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 Tanis 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 Cr. <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 01`: <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal -Cl <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Sea led By: <br /> PUMP INSTALLATION: Contractor W <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done .� ,1.) P <br />! DESTRUCTION OF WELL: Well Diameter Approximate Depth <br />' Describe Material and Procedure' <br /> — <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I pill call for a Grout Inspection Oftr gr Zan4diinall inspection. <br /> Signed Ie: _?! Date: lel'` VfDraw Pln on Reverse Side) <br /> 3 FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By � r Date <br /> to <br /> Additional Comments: <br /> Phase Il Grout Inspection hase Ili Fiqal Inspection <br /> f Inspection By Date Inspection By Date <br /> 1�,ee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July t &Received By JuVy 31 <br /> REMIT <br /> BASE- EXPLANATION BILLING REMITTANCE $ r• <br /> DATE DATE AMOUNT DUE CHECKED <br /> REMITTED <br /> FEE AMOUNT <br /> LESS YS <br /> PRORATION . <br /> I PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> o 3� S 3l <br /> I Received by �y.� <br /> Oate � ^� <br /> APPLICANT—RETURN ALL COP Receipt No, Permit No. Issuance Date „r Mailed Delivered <br /> __ !ES TO.' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 21tD8�STOCKTON,CA 95201 <br />