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Applications Will Be Processed When Submitted ProgenyL:omp �. y `i ! �l E� <br /> APPLICATION P`] <br /> M <br /> MP&WELL <br /> (For Non-Transferable, Revocable, S spendable) <br /> ENVIRONMENTAL HEALTH EZRAR 2 7 1981 <br /> WATER QUALITY "fI; f ^ATE) ,90,'nstalf�tNewO� hls�e AL,ribed.This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct a <br /> made in compliance with San Joaquin, Cou ty Ordinance No. 1862 and the rules and regulati y�tWTe ��o l�Health District. <br /> Site Address .:I �-,6 r r '`I <br /> Phoned 6 3 3 , <br /> Owner's Name City + <br /> Address 3 311 <br /> Contractor's Name License#I��-3 73 Business Phone <br /> Emergency Phone _ �� g T <br /> Contractor's Address ' ✓ No 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (TION� WE W ABANDONMENT ❑❑ OTHER 0 RECONDITION❑P INSTALLATION ON � PUMP REPAIR TRUCTION ❑ <br /> WELL CHLORINATION <br /> REPLACEMENT❑ Pit Privy <br /> Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field <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 <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGADOMESTIC/PUBLIC Depth of Grout Seal <br /> d IRFl1GATION ❑ GRAVEL PACK <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL �[� urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor C3 <br /> P. <br /> Type of PumpH. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 /> 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." c <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 wor`kman's compensation laws of California."' µ <br /> I w' all f a Grout 1n ction prior io routing and a <br /> alinspection. �� <br /> Title: Date: <br /> Signed X <br /> '(Draw Ian on Revers ide) <br /> FOR DEPARTMENT USE ONLY 99 <br /> PHASE I L Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase Il Grout Inspection ase HI Inspection ,yam <br /> Inspection By Date Inspection By <br /> Fee Is Due'_ ❑ ANNUALLY ❑ PER UNIT ❑ PER SiTE El EACH ❑ January 1 &Received By January 31 jury 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .3�o g <br /> Received by Date <br /> Receipt No. Permit No. issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES <br /> 1601 E.HAZELTON AVE..P.O.Boz 2009 STOGKTON,GA 9520 <br />