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N Apptrli ill Be Processed Wh mined Properly Completed.Be Sure To Sign The Application. <br /> OFFICE USE: V 8_1981, <br /> y1g81 APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) f <br /> . _ r--PL)MP&WELL <br /> SAN J0AQ1J1NElfiW*f6NMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) HEALTH IDIS- ICT WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or installthe work herein described.This application is <br /> made in compliance with S 'p.County Ordinance No. 1 6 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address SS City/Town -�-� <br /> Owner's Name Phone 2 <br /> Address PA City—,L :Z, <br /> c� <br /> Contractor's Name 4° License#2, &65% Business Phone2- 9�rf d � 3 <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes t/ No � <br /> TYPE OF WORK (CHECK: NEW WELL 11 ' DEEPEN ❑ RECONDITION C1 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ l� ? <br /> REPLACEMENT[] I b <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 a <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 ?I,2�Z <br /> Type of Pump A—� H.P. / <br /> -PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r <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 San1permit <br /> y <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:"1 certify that in the performance of the work foritis issued, I shall not employ any person in such manner as to become subject to workman's compensation la "Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the ws <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call to a t Inspection prior to grouting and a final inspe ti <br /> Signed X Title: � � <br /> 01 Date: <br /> I# (Draw Plot Plan on Reverse Side) <br /> i- <br /> - -FOR DEPARTMENT USE ONLY f <br /> PHASE I �e7 Date �l`�� <br /> I Application Accepted By <br /> 1 <br /> Additional Comments: <br /> Phase 11 Grout Inspection as III Final Inspection z <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 /> HEMIT l <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> ,i AMOUNT . <br /> r [ � 4 L4 _� <br /> FEE <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> I <br /> OTHER <br /> i <br /> . DTHER - - <br /> I Received by lbate t Receipt No. Permit No, Issuance Date Mailed Delivered <br /> 1 <br /> { APPLICANT—RETURN ALL COPIES-TO: ''ENVIRONMENTAL HEALTH PERMITiSERVICES 1601 E.HAZELTON AYE.,P.O.Box 20D9 STOCKTON,CA 11111 <br />