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Applications Will Be Processed When Submitted Properly Completed. Be SuriMp <br /> To Si n The Application. <br /> FOJ; OFFICE USE: APPLICATION � � <br /> (For Non-Transferable, Revocable, Suspendable)� &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> e/1d, <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 0 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install V erelndescribedThisapplication is <br /> made in compliance with San Joaquin�County Ordinia�+ce N 1862 and the rules and r gulations of the San Joaquin o I ealth District. <br /> Exact Site Address Z .—C -��' g. City/Town <br /> Owner's Name 4n f G A-V/,* �� Phone <br /> Address ?-'3�t _5' "_ , City <br /> Contractor's Name " � t� . License If Business Phone <br /> Contractor's Address Z- �mergency Phone -h <br /> Is Certificate of Workman's Compensation insurance on File With SJLF,I ? Yes No W <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ RECONDITION DES <br /> r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 5I PUMP REPAIR <br /> REPLACEMENT❑ i.! <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy V <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 /> 10 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 Inst led By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ;W State Work Done <br /> r <br /> 42 <br /> DESTRUCTION OF WELL: Well DiameteApproximate Depth <br /> Describe Material and Procedure } <br /> C4 <br /> 1 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 will call for a Grout Inspec Odor ting a a final inspection. <br /> Signed itle: ��� Date: <br /> (Draw Plot Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 ���' <br /> Application Accepted By Date <br /> Additional Comments: <br /> 1MV�Phase II Grout Inspection Phae III Final Inspection <br /> InspectionBy Date Inspection By Date <br /> r• <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JWy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE OATH RE ITTEp AMOUNT <br /> FEE �l� �I�� � 14S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No Issuance We Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />