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Applications Will Be Processed When Submitted Properly Completed. ur`ito4 g�3Th&A�li o1UJ <br /> FOR OFFICE USE: a APPLICATION , <br /> (For Non-Transferable, Revocable, Suspendjl g� sr ag�k WELL <br /> ENVIRONMENTAL HEALTH PERMIT II tfY �sr <br /> WATER QUALITY sfkan? kq�;;QWNLOC L <br /> (COMPLETE IN TRIPLICATE) p � �rj Uld.This application is <br /> Application is hereby made to the San Joaquin Local Health District permit construct and/or Inst o <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the We and regulations of the San oaquin Local Health District. } <br /> Exact Site Address - City/Town <br /> Owner's'Nam ' " r� _— -P f Phone <br /> e <br /> City ' :/ I <br /> Address � <br /> - f 11� License# Business Phone �v� <br /> Contractor's Name <br /> } <br /> Contractor's Address " E1 � Emergency"Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL( DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION 11 WELL ABANDONMENT 93' OTHER E] PUMP INSTALLATION p PUMP REPAIRO <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 /> ❑ INDUSTRIAL ❑ CABLE TOOL" Dia. of Well Excavation <br /> UErDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> R'IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> E] CATHODIC PROTECTION 11ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information d <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump AW H.P. <br /> PUMP REPLACEMENT: tate Work Done <br /> PUMP REPAIR: ❑ State Work Done p r� <br /> DESTRUCTION OF WELL: Well Diameter 91 011f Approximate Depth 21a v< <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 forwhich this <br /> permit is issued, I shall employ-persons subject to workman's compensation laws of California." <br /> k 1 will call for a Grout lnspe tion prior to grouting and a final inspection. <br /> I Signed X <br /> Title: a� Date.. <br /> 1-0 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE i f pM� f-'P� sl Date �� <br /> Ll <br /> Application Accepted By <br /> Additional Comments: <br /> Phase It Grout inspection P se Ili Final Inspection <br /> Date Inspection B Date <br /> Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By,January 31' " ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE – $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - - - - <br /> i <br /> LESS <br /> PRORATION / ;i I1 } <br /> PLUS ' - 46C6I k-eie mL,_-ef <br /> i PENALTY <br /> OTHER J/ J �r <br /> l OTHER ,. D 6 Cf CJlI! <br /> X6(0 1 S�iJ <br /> Received by. Date 'Receipt No. - Permit No. - --Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMINSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 _ STOCKTON,CA 95201 1 <br />