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Applications Will Be Processed When Submitted Properly Compi� `C� Su T' iT plication. <br /> FOR OFFICE USE: APPMATI'f�TV sl, N <br /> (For Non-Transferable, Revocable,t spendable) P&WELL <br /> ENVIRONMENTAL HEALLYA PERW- <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application ishereby made totheSan JoaquinLocalHealthDistrictforapermittoconstr�e attd/bf16A-Aut Jw Aelndescribed.This application is <br /> �ia,. 'f�th�� <br /> made in compliance with S n o u�j-Cgpnty Ordinance No.>862,and t rules and regal a'I�o (a uinALocal Dist ict. <br /> Exact Site Address % y__1 City/TownG�' !� . <br /> Owner's Nam <br /> AddressCity <br /> Contractor's Name +� vM� License` Business•Phone J <br /> Contractor's Address ' Emergency Phone �'�� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes No i <br /> TYPE OF WORK (CHECK): NEW WELL'❑ DEEPEN ❑ RECONDITION❑" DESTRUCTION[-]'- <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ _ _ <br /> DISTANCE TO NEAREST: Septic_ Sewer Lines Pit Privy <br /> Sewage Disposal Field '* Cesspool/Seepage Pit Other <br /> Y <br /> Property.Line Private Domestic Well Public Domestic Well <br /> rt <br /> INTENDED USE TYPE OF WELL 1~ <br /> ` ❑ INDUSTRIAL ' 40"CABLE TOOL.— "' Dia. of Weil Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: j/ State Work Done <br /> DESTRUCTION OF WELL: ' Diameter <br /> .Well -. a Approximate,Depth <br /> Describe Material and Procedure <br /> ( <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 forwhich this permit �^ <br /> is issued, I shall ploy any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's g or sub-contr ng 'gnature certifies the following:"ei. <br /> that in the performance of the work forwhich this <br /> per I I shall emplo person subject to workman's compea ofCalifornia." <br /> r <br /> Ill t Ins ecti n rior grouting and a final inspe <br /> Signed X, Title: Date: <br /> Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I .. .t <br /> Application Accepted By Date <br /> � <br /> Additional Comments: <br /> Phase II Grout Inspection has, Ill Fin Ins ection <br /> Inspection By Date Inspection By�, 7 �Date <br /> 4r_11_ lee-Sr-.;t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑'January 1 &Received By January 31 ❑ July 1 a,Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE Lj T <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY / %�/ l'�I- ' �.�v / -�[. �UdT / 4:Z.0_ <br /> OTHER 4/ y /ev <br /> or <br /> OTHER <br /> Received by Date Receipt No. Permit No. Isguance.lbile ,Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 05201 <br />