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Applications Will Be Processed When Submitted Properly Completed. B ��} jeAp0Jca1]*. LW <br /> 1FOR OFFICE USE: APPLICATION �,J <br /> (For Non-Transferable, Revocable,Suspends NOV r� Q IQ,UAP&WELL- � <br /> ENVIRONMENTAL HEALTH-PERMIT vY I$ <br /> (COUAP <br /> IN TRIPLICATE WATER QUALITY SAN ,1QA�?��N FOCAL <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install Vaff�AbTNfeDL&Ton eTThisapplicationis <br /> made in compliance with S n Jo�1a uin C my Ordinance No. 1862 and the rules and regulations of the San Joaquin Lqcal Health District. <br /> Exact Site Address o J) City/Town �_�_ Cl <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address �N Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File 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 Wel! Public Domestic Well I <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 ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout 7 <br /> ❑ DISPOSAL E] OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> r <br /> PUMP INSTALLATION: Contractor <br /> H.P, lCalifornia." <br /> Type of Pump PUMP REPLACEMENT: ❑ State Work DonePUMP REPAIR: State Work Done DESTRUCTION OF WELL: Well Diameter Approximate DepthDescribe Material and Procedure <br /> r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certifythat in the performance of the work for whicis issued, I shall not employ any person in such manner as to become subject to workman's compensation laws ofContractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work fo <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California:" <br /> I will cal r a Grout Inspec n pri to grouting and a final inspe ion. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Aeverse Side) <br /> ORD PARTM T USE ONLY <br /> PHASE <br /> Application Accepted By— <br /> Additional <br /> y k Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Ph III Final Inspection <br /> Inspection By Date N Inspection B Date�� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> .A BILLING REMITTANCE $ . i <br /> BASE EXPLANATION DATE DATE REMITTED ''MOUNT DUE CHECKED , <br /> AMOUNT <br /> FEE <br /> { <br />[ LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 'OTHER <br /> k <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered JJ������JJ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.Q.Box 20119 STOCKTON,C![�+D1L <br />