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Applications Will Be Processed When Submitted Properly Completed. r�? <br /> o�i�n__If7ion <br /> h""34p . <br /> FOR OFFICE USE: APPLICATION' FIS# 144jff1 <br /> i <br /> (For Non-Transferable, Revocable, pen able) PUM ELL <br /> ENVIRONMENTAL HEALT- H`PE&y,M 'i <br /> 2 41982 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Dlstrictforapermittoconstruct a r5r;in ttsw 1 �crl 9 <br /> ,. o�i�C. ribed.This application is <br /> made in compliance with San Joaquin County Ordinance No 1862 and the rules and regulatip�t�s fff4 ba9LGg�i+4,QT <br /> Exact Site Address '� '"` f cal Health District. <br /> 3/ �9 <br /> City/Town <br /> Owner's Name <br /> Address eD �r r ,... } — Phone.. <br /> ;. 6 a <br /> - City <br /> Contractor's Name w%r` w. License#"L 4 2 3� Vis" � n 1 <br /> Business Phone__' <br /> Contractor's Address 4 F e? Emergency Phone I <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 0 PUMP REPAIR❑ <br /> REPLACEMENT❑ " <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy i <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE 5 3 TYPE OF WELL�-- .— <br /> ❑�INbUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION .x ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL + E ❑ OTHER Other Information i <br /> ❑ GEOPHYSICAL Surface Seal Installed By: i <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: 0 State Work Done , <br /> H.P. <br /> PUMP REPAIR. ❑ r_ <br /> State Work Done .-- <br /> DESTRUCTION OF WELL: Well Diameter <br /> Approximate-Depth <br /> s - 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 6f 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 forwhich this <br /> permit is issued, I shall employ persons subject to,workman's compensation laws of California." <br /> t' I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed XYh. r a ; <br /> r �_ _ '.. Title: Date: J' <br /> E <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I W� � <br /> Application Accepted By T�`\ - Date q ! <br /> Additional Comments: <br /> Phase II Grout inspection hese III final fns action <br /> Inspection By Date Inspection By Date —7`0— F4 <br /> Fee Is Due: ❑ ANNUALLY '- ❑ PER UNfT- ❑ PER SITE - ❑ EACH - ❑ January 1 &Received By January$1 <br /> ❑ July 1 &Received-By•auly 37 ; <br /> _ BASE - EXPLANATION BILLING . .REMITTANCE $ REMIT <br /> DATE DATE REMITTED 4MOUNT DUE CHECKED <br /> , 1 AMOUNT <br /> FEE 4 - b. _ _ 4T . <br /> PRORATION <br /> t <br /> PLUS y <br /> PENALTY <br /> OTHER . <br /> OTHER <br /> Received by - Date Receipt No.: - Permit No -I suan a Date - Mailed <br /> -Delivered ... <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 ! <br />