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.. .. -- •.•••.•. ...,.........4.,, r..v y --w—vu.—ourq 1paign IneAppimanon. <br /> FOoFFlc>" USE: APPLICATION <br /> i {For Non-Transferable;f'ievocable; Suspendable) , <br /> _= <br /> ENVIRONMENTAL HEALTHVERMiT` f;;,• . <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit ta!�Constructand/or install the work',hereimdescribed.Thisapplicationis j <br /> made in compliance with n Joaq in County Ordinan e•No. 1862 and the rule*;:and-regulations of the Ban J04uin• "oc�ai Health District. I <br /> Exact Site Address <br /> /Tt7 <br /> City1Iy►1' '— <br /> . . p' d <br /> Owner's Name =i2 �t// NF-r Phone-_ 47Q ,7–j•�dr' /. <br /> ,,Address . r City r <br /> -'Contractor's Name L A" �/1`''-S License# X73 Busine13a phone_ ' 96 <br /> Contractor's Address -&46 Emergency Phone <br /> 'Is,Certificate of WoMman's Compensation Insurance on File'With SJLHD? " =Yes <br /> TYPE OF WORK (CHECK): - NEW WELL El'. DEEPEN O RECONDITION❑ DESTRUCTION 13 _m <br /> WELL "6ILORrNATk>3N 2- "'WEL"L-:ABANDONMENT ❑ OTHER'❑ PUMP INSTALLATIGN W •"PUMP-REPAIR <br /> REPLACEMENT❑ <br /> -DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage DisposaLPield Cesspool/Seepage Pit Other _ <br /> ";,PropertyftJne" Private 0ameg1jc-Well' 1. Public Domestic Well.— <br /> INTENDED USE TYPZ'OF WELL: <br /> ❑.INDUSTRIAL » ❑,CABLE TOOL Dia. of Well:Excavation s <br /> ❑" DOMESTfC/PRIVATE :, ` ❑ DRILLED Dia. of••Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of'Casing <br /> ❑ IRRIGATION 0 GRAVEL PACK Depth-of Grout-Seal <br /> ❑ CAT.HODIG..PROTECTION ❑ ROTARY . Type of Grout <br /> ❑ DISPOSAL _ ❑'OTHER -Other,Information <br /> ❑ GEOPHYSICAL ;. Surface Seal Installed F <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P, <br /> PUMP REPLACEMENT: State Work Done - <br /> "PUMP'REPAIR: State Work Done <br /> :DESTRUCTION OF-WELL: - Well Diameter <br /> r - _ .Approximatr:, Depth �:"- 4 <br /> Describe Material,and Procedure <br /> I hereby certify-that-I have prepared this application and that"the,work will be done,if! rircordance With San Joaquin County Q1 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local-:Health District. <br /> Home owner-or"licensed agent's"signatureaertifies the'tollowing:"I certify that inthe performance of Ilia work forwhich this permit <br /> _:is issued, 1 shall not employ any person'.:in such manner.as to.become subject to workman's compen9ation laws of California." <br /> Gbnhactor's hiring or sub=contracting signature ceriffieis:lhe.tolfowing:"I certify tbatJn.,tho performance of the work for which this <br /> 7. p� rmitJs issued, I shall employ persons subject to workman's:,compensation:tatas-of <br /> II pwillgyopll for a Grout-Inspection prior to grouting-and a final inspection. <br /> Signed X 't• '/ nn i.i Title: ----:Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE,I- <br /> Application Accepted By I . <br /> Date. <br /> Additional Comments: <br /> Phase II Grout Inspection- tial Inspection <br /> �,•,,.,• <br /> Inspection By Date Inspection By Date <br /> _>Fee Is Due:-0 ANNUALLY `.11PER UNIT ❑ PER SITE '-"❑ EACH -0 January 1 &Received By January-71• - --❑ July 1 &Received By July 31 <br /> REMIT <br /> RASE - EXPLANATION .BILLING',, _- REMITTANCE S - - -AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> _ PRORATION _ <br /> PLUS <br /> .PENALTY <br /> f <br /> OTHER <br /> OTHER ; <br /> _ J <br /> Received by DateReceipt No. Permit NoIssuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON„V5201 <br />