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-App <br /> llca io s Vllill ie'7N''ce�ser�!"�4fh(r� Abmitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: .r 1 APPLICATION /fr <br /> CEPQ RI Non-Transferable, Revocable,Suspendable) fv <br /> J �'E1MA&WELL <br /> EV,, ,!FMMENTAL HEALTH PERMIT <br /> 1�rt <br /> 15 <br /> 3"'k41 ` <br /> rr 1 <br /> (COMPLETE IN TRIPLICATE) _ s V �'� } � WATER QUALITY <br /> Application is hereby made to the S4A9r,{ 1giJirlLocalHealth District fora permit toconstruct and/or install the work herein described.This application is <br /> made in compliance wiith S Joaqui County.Ordinan a No. 1862 and th rut s and regulations of the San o u cal Health District. <br /> Exact Site Address / t� G City/Town <br /> Owner's Name U (" Phone ! <br /> Address <br /> ity <br /> Contractor's Name License#' <br /> u s P one <br /> Contractor's Address EmergencyPhone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ 4 DESTRUCTION❑- d <br /> WELL CHLORINATION 0- WELL ABANDONMENT ❑ OTHER ❑ PUMP- INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 0' err <br /> i t : <br /> DISTANCE TO NEAREST: Septic Tank _ Sewer Lines Pit Privy <br /> Sewage Disposal Field T Cesspool/Seepage Pitt Other <br /> Property Line Private Domestic Well Public Domestic Well ` <br /> INTENDED USE TYPE OF WELL # <br /> INDUSTRIAL E] CA13LE TOOL Dia. of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia, of Well Casing ` <br /> OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing i <br /> ❑ IRIGATI <br /> ON ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ ATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> GEOPHYSICAL <br /> - � Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. <br /> ,T�Y,�p ... Pump HP <br /> PUMP REPLACEMENT: State A <br /> ork Don,,, I e 1 r <br /> PUMP REPAIR: ❑ State Work Done F I <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'Iaws, 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 workfor v✓hi h 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 /> 2callr a Grout I pectian o g�o . a al inspection.Signed X itle: Date- <br /> (Draw <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY 4 <br /> PHASE I � <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection r f Mas III Final Inspection �y ; <br /> Inspection By Date Inspection IBate <br /> 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑-EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING . REMITTANCE $ REMIT <br /> BASE' EXPLANATION AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> FEE.- 's LJ <br /> O <br /> I <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ` <br /> Received by Date Receipt No,' - Permit No. fssuande Date ..Mailed_ a Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />