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Applications Will BeProcessedWhenSubmitteO F'ropeny iomplgre aea� ITT"N"" <br /> FOR OFFICE USE: APPLIGAT�O' (For Non-Transferable, Revocabl d le <br /> s►� UMP&WELL <br /> ENVIRONMENTAL HEAL ERNbN 23 1979 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY '`�U W <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstru or tR�t,Wrk(F9i described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and reguu mi r o e Cltl�Y �t�Local Health District. <br /> Exact Site Address ity/Town E 'Gw <br /> Owner's Name J2 Phone ` � J� <br /> Address a d City - <br /> Contractor's Name License# 4-�-�)3 Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN C] RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONV PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines . Pit Privy - <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well - <br /> INTENDED USE TYPE OF WELL <br /> Dc' <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - - P <br /> ❑ DOMESTIC/PRIVATE Cl DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> © IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal T <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> © DISPOSAL 11 OTHER _ Other Information -- <br /> ❑ GEOPHYSICAL Surface Seal Installed By: w <br /> PUMP INSTALLATION: Contractor 5 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <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 /> 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 Inspection prior to grouting and a final inspection. <br /> Signed X j2�Title: �'Y? Date: <br /> (Draw Plot Plan on Reverse Side) <br /> R D ARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By """ Date 7P <br /> Additional Comments: <br /> Phase II Grout Inspection Phas III Fin rinspection l � <br /> Inspection By Date Inspection By Date /V� <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Nr PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July I &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED pf/ AMOUNT <br /> FEE G [.d/ Y <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. issuance[fate 1 Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />