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Applications Will Be Processed When Submitted Properly Completed.,BeSuY�e"1' 'Sfu <br /> +lcaslon. <br /> FOR OFFICE USE: APPLICATI�+ '1, } � k�a W <br /> rt (For Non-Transferable, Revacabie,;S a dable) P&WELL <br /> ENVIRONMENTAL HE�L ' PEgW T t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , . ... ,r <br /> t <br /> n described.This application is <br /> Application is hereby made totheSanJoaquinLocalHealthDistrictforapermittoconstr c a_rad/a',jfl f lUt i ance No. 1862 and the rules and I�a�ti� s c�#th� rLo al Health District. <br /> made In compliance wit San Joaquin County Ord A C�y/Town <br /> Exact Site Address wit <br /> -7 <br /> Ph one <br /> Owner's Name City <br /> Address <br /> License# Bu�sin/ess Phone <br /> Contractor's Name , Emergency Phone <br /> Contractor's Address - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ►� No <br /> TYPE OF WORK (CHECK): NEW WELL Cl DEEPEN ❑ RECONRITION❑ DESTRUCTION <br /> ❑� <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑`-puMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ t <br /> Sewer Lines � -+� " Pit Privy'- <br /> DISTANCE TO NEAREST: Septic Tank wF <br /> sCesspool/Seepage Pit,— Other I <br /> Sewage Disposal f=ield - f , <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL, ell i <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia- of Well Excavation. <br /> 11DOMESTIC/PRIVATE ❑ DRILLED-` —Dia:of Well Casing <br /> 11 DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑;,.CATHODIC PROTECTION <br /> ❑ ROTARY Type of Grout �y <br /> ❑-DISPOSAL t 1:1OTHER Other information I <br /> S face Seal Installed By: <br /> ❑ GEOPHYSICAL �►, .._ 9 ;�""'� 'r•� -` �/ <br /> PUMP INSTALLATION: Contractor <br /> N.P- <br /> Type of Pump <br /> PUMP REPLACEMENT: � <br /> 11 State Work DonerIL <br /> PUMP REPAIR: Mr ate Work Done t v~ <br /> A , f'-'? Approximate Depth ! <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Proce'dure:_ 1 <br /> I hereby certify that I have prepared this application and 16at the work will be done in accordance with San Joaquin County�s <br /> ordinances, state laws, and rules and regulations of the Sani:Joaquin Local Health District, <br /> I <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 oLCalifornia." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work permit is issued, I shall employ persons;subject to workman's compensation laws of California." <br /> I will I fora rout Ins on prior to gr ting and a final,irispecMe. Date <br /> Signed X <br /> (praw Plot Plan on Reverse Si e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: f. <br /> Phase 11 Grout inspection,, Phas II Final Inspeciion/� . <br /> K Inspection By—�.�i���� DateI. Inspection By Date <br /> f <br /> ` Fee I5 Due: ❑ ANNUALLY PER UNIT LJ PER SITE ❑ EACH E3 January 1 &Received By January 31 ❑ July 1 &ReceiveRdEB�kTuly 31 <br /> RASE ? EXPLANATION BILLING REMITTANCE $ AMOUNT DUE- CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> .44 <br /> FEE <br /> LESS <br /> PRORATION _ - <br /> �y <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' t <br /> OTHER <br /> Y Date Receipt No. Permit No. Issuan a Date - Mailed Delivered <br /> Received by <br /> APPLICANT'.—RETURN At-L-COPIES-TO: <br /> 'MENTAL HEALTH PERMIT/SERVICES 1841 E.HAZELTON AVE.,P.O-Box 2049 STOCKTON,CA 95201[-=y.-i� <br />