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Applications Will Be Processed When Submitted Properly Completed. Be Sltire�o{,5i nrV �A lic�iion <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable Revocable, Suspend <br /> /JUL 2 �1� <br /> MP&WELL <br /> E <br /> ENVIRONMENTAL HEALTH PERMIT 0 19 <br /> ..� _ WATER QUALITY �.I i�: iIN g`CAL <br /> (COMPLETE IN TRIPLICATE)P!1![7`i1J i.i�-C.�-! �. Q j�,; _ - s`_ y <br /> Application is hereby made totheSan Joaquin Local Health Districtforapermit toconstruct and/or instalf;th-, rbci?er�Alicingz.Thisapplication is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address doeAi� S�4L _-ro-A .-�Cr. p`�-�sQ�3�pL1� Cily/Town TU-V1 <br /> Owner's Name�lft`�Jl -Un f I�n � �[5;._ - Phone ? — (o 14 1 <br /> Address City <br /> Contractor's Name Y Q�•4 - - License S37 qn B iness Phone az ��^^ <br /> Contractor's Address _� . Emergency Phone d`� r l <br /> I Is Certificate of Workman's Compensation Insurance on t=ile With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ + <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIOryq PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line,;l7.0 I 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 /> I ❑ GEOPHYSICAL rface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor t1 C.- <br /> t Ty e of Pump _ <br /> - + - H.P. — [. <br /> PUMP REPLACEMENT: State Work Done t^.�COY <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 /> i 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 will 11 for a Grout Ins 1 n2prioltgroutland a final inspection. <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> k FOR DEPARTMENT USE ONLY <br /> PHASE I QOM <br /> I Applications ecepted By ' , `1 — -- Date +� <br /> Additional-Comments: " <br /> Phase II Grout Ins ection <br /> P Phase III Fi Inspection <br /> r -Inspection By V1,kI Date Inspection By1_�� � --- Date <br /> E. � _ <br /> Fee IS Due: 11 ANNUALLY El PER UNIT El PER SITE ❑ fAGH ❑ January <br /> '1 88Re�c�e�ivea }Byaanuary 31 ❑ July 1 &Received By Juky 31 <br /> BILLING .REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE --.- REMITTED 4AMOUlJ T9_U_F—� CHECKED <br /> �A.MOUNT.� _ <br /> FEE =' <br /> LESS <br /> PRORATION <br /> PLUS r <br /> PENALTY I <br /> OTHER [ <br /> OTHER a !k <br /> Received by —Date ,Receipt No.. Permit No. -- Issuance ate Mailed- - Delivered 3 <br /> S APPLICANT—RETURN ALL COPIES TO:"�4ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE P.O.@ox 2009 STOCKTON,CA 95201 <br />