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Applications Will Be Processed When Submitted Properly Completed. Be SurAT Sjaq T,1eARpfiction. <br /> ' FOR OFF,TCE USE: <br /> APPLICATION ' tl i ; <br /> (For Non-Transierable, Revocable, Sus pe e <br /> PU WELL <br /> ENVIRONMENTAL HEALTH PE rNOV g 1980 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/o/arp"ll 1�nwyrtk�h�rein rCltiescribed.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations FqE),,eL Foaq r c 1T alth District. <br /> Exact Site Address h. G City/Town `C <br /> Owner's Name U. S, �1� �1{7�.� �nlC Phone <br /> Address-?, cityiJ"'�.x_iL[=POR—® <br /> Contractor's Name � =BRING P-OrnP License# fD3 I Business Phone�� --56 <br /> "-> Emer <br /> Contractor's Address g enc y Phone <br /> '42- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _J - <br /> TYPE OF WORK (CHECK): NEW WELL© DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ 2 } <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy , <br /> Sewage Disposal Field Cesspool/Seepage Pit Other 17111 <br /> Property Linel Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> E] DOMESTIC/PRIVATE x4=:;� ❑DRILLED �- Dia. of Well Casings <br /> ❑ DOMESTIC/PUBLIC"_. ~ _ �?•❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION v `'•b`GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ 'ROTARY Type of Grout <br /> " <br /> © DISPOSAL `•❑ OF ERS, Other Information <br /> OT ER <br /> ❑ GEOPHYSICAL j l Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ype of Pump H.P. <br /> PUMP REPLACEMENT: Stale Work DoneaLme - L54-_ _9_. ion <br /> I <br /> PUMP REPAIR: - J- ❑ State Work Done # *- W <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure. I <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 /> Home owner 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 /> a <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I w I a G ut Inspection prior to grouting and a final inAverse <br /> ' "J <br /> f Title: - Date: 11-171 <br /> 1 Q v t <br /> Signed X { <br /> (Draw Plot Plan on e) 1, f <br /> r 9r . } <br /> a FOR DEPARTMENT USE ONLY fir' 0 G;^ ��' <br /> PHASE I <br /> Application Accepted Dafe,� ' <br /> Additional Comments:By > <br /> Phase Il Grout Inspection Phase 10'nal Ins : ction <br /> Inspection By Date Inspection By ate <br />� Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE ❑ EACH C1January 1'&Received By January 31 ❑ July 1 &Received By July 31 l <br /> I, REMIT 'I <br /> BA�SE EXPLANATION BILLING HEM#TTANCE $ AMOUNT DUE CHECKED <br /> } DATE DATE REMITTED AMOUNT <br /> FEE � <br /> LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> I� OTHER <br /> i <br /> OTHER { <br /> Received-by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 , STOCKTON;CA 95201'� <br />