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Applications Will Be Processed When Submitted Properly Completed. re To Sign The Applicatio i <br /> FOfiU FVCt USE: APPLICATION MAY 1 1980 i <br /> (For Non-Transferable, Revocable, Suspendable) <br /> { PUI P&WELL <br /> ENVIRONMENTAL HEALTH PERMI1SAN JD�`;QUIN LC <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY HEALTH DISTRICT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with.San Joaquin County Ordinance No. 1862 and the rules and regulations of the San oaqutn L cal Health District. <br /> - <br /> Exact Site Address 1� i ©S/ City/Town .SZ' �'J <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name . S d.�� License# —7 � Business Phone <br /> � ` . <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 ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRM <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 /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ` . <br /> ❑ IRRIGATION ❑ GRAVES_ PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information d <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: IN 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wiq472. <br /> ion p i to grouting and a final in7t4fi� r <br /> Signed X Title: Dater / 1 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMEN USE ONLY <br /> PHASE I <br /> Application Accepted By e,7 Date <br /> Additional Comments: 17 <br /> i Phase II Grout Inspection It Fi I <br /> II r <br /> Inspection By Date Inspection B <br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH ❑ n y 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> - BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE O q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r OTHER <br /> OTHER <br /> �r1o� 5�r��� �3( ?� b5(�3 <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: _ ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />