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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PllM &WELL <br /> ;! ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora 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 Joaquin Local Health District. <br /> Exact Site Address +� a City/Town <br /> 1 s= Phone= <br /> Owner's Name <br /> City <br /> Address <br /> Contractor's Name . r License#„, 53'213 Business Phone 5!!Y9880 ' ti <br /> Contractor's Address Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A-," No <br /> TYPE OF WORK(CHECK): NEW WELLr❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION H PUMP REPAIR❑ <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 ek <br /> A INTENDED USE t TYPE OF WELL . <br /> r ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well',Excavation <br /> ® DOMESTIC/PRIVATE 11DRILLED Dia. of WeII;Casing +V: <br /> ❑ DOMESTIC/PUBLIC EIDRIVEN Gauge of Casing <br /> 11 IRRIGATION 11GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION .�❑ ROTARY Type of Grout <br /> ❑ DISPOSAL --, ❑ OTHER Other Information <br /> '�-+✓� t.,% +. '' Surface Seal Installed By: <br /> ❑ GEOPHYSICAL .:.e ^-�- <br /> TALLATION: Contractor <br /> (Type of Pump H.P./ S' <br /> PUMP REPLACEMENT: �❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL- Well Diameter ; Approximate Depth <br /> Describe Material and Procedure <br /> . ly <br /> I hereby certify that I have prepared this applicati,o6,n and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, and rules and regulations ofathe.San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifiegthe following:"I certify that in the performanceof the work.forwhichthis 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 toFworkman's compensation laws of California." <br /> I 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X <br /> Title: __� i1�,.. .,... Date: °Z <br /> (Draw Plot Plan on Reverse Side) <br /> ' FOR-DEPARTMENT.USE�UINLY-44 Ak%;M kllr! <br /> ( PHASE I A 0, <br /> j Application Accepted By ' re Date �0 <br /> Additional Co_ mments: <br /> j as I Final inspection <br /> Phase it Grout Inspection <br /> Inspection By ate Inspection <br /> By <br /> f Date <br /> Fee Is Due: ❑ ANNUALLY [:)'PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &-Received By January 31 ❑ July 1 &ReceiveRd By July 31 <br /> BASE EXPC'ANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> 1 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS 1 <br /> PENALTY, <br /> OTHER <br /> OTHER <br /> -Received by - Date Receipt No. - Permit No. Issu ce❑ to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />