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Applications Will Be Processed When Submitted Properly Compl�etedjae�Su��T�Sigtt T0A p�' Ila"• ' ` <br /> FOR OFFICE USE: <br /> APPLICATION t, Vj �Ul <br /> (For Non-Transferable, Revocable, Spendable) L) WELL <br /> ENVIRONMENTAL HEALT PERNfif-P 21 198 <br /> morac� <br /> WATER QUALITY 0 le Z ^ �I / <br /> (COMPLETE IN TRIPLICATE) g8S a (arG�c�c1�D2 . nn l . �r 1�I�'� �-�'�' <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct rlYo�i�'t4thervrlokl hr�1P described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulat►orts` rt b--tt n Joaquin Local Health District. <br /> Exact Site Address City/Town al <br /> V"2 <br /> Owner's Name ►" rnJ Phone 9`��" ' <br /> Address City <br /> ` <br /> Contractor's Name ��' i��:�. � �•-�'-�^ License# ,7s Business Phone_fir_� — <br /> Contractor's Address �• ��.? ,Z 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 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 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. ' <br /> PUMP REPLACEMENT: ❑ State Work Dane <br /> PUMP REPAIR: © State Work Done PAI 0 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth - pn <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> IPPwill tali for a`Grout Inspection prior to grouting and a final inspection. <br /> Signed X !;?G t t��'� Title: 41 <br /> �^ Date: <br /> (Draw Plot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �rAres <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P ase 111 Final Inspection <br /> Inspection By Date Inspection By 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> J by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> F <br /> !CANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSEgVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 570CKTON,CA 9520 <br /> f <br />