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Ap (i�tioris Will Be Processed W ubmitted Properly Completed. Be Sure To Sign The Application. <br /> [FOR OFFICE USE: AUG _2 19$2 APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> 5�14� �n{ ? RUMP St WELL <br /> (COMPL "TE IN TRIPLICATEALT( ®IST <br /> hONMENTAL HEALTH PERMIT <br /> ) WATER QUALITY <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 C unty Ordina c No. 1862 and the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address / 9C1,111 cv-- <br /> Owner's Name City/Town <br /> Address1 Phone <br /> Contractor's Name , r� City_/17e�., M., <br /> License#�, Business Phone �3 S <br /> Contractor's Address <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION�� PUMP REPAIR❑ t <br /> REPLACEMENT❑ � <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> INTENDED USE Public Domestic Well <br /> Property Line Private Domestic Well Other <br /> ❑ INDUSTRIALTYPE OF WELL <br /> 0 CABLE TOOL Dia. of Wel! Excavation <br /> El DOMESTIC/PRIVATE <br /> GRILLED Dia, of Well Casing <br /> El DOMESTIC/PUBLIC <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK <br /> 13CATHODIC PROTECTION 0 Depth of Grout Seal <br /> ROTARY <br /> ❑ DISPOSAL Type of Grout <br /> 1-1 GEOPHYSICAL <br /> OTHER Other Information <br /> PUMP INSTALLATION: S rface Seal Installed By: <br /> Contractor /� .6 <br /> Type of Pump <br /> PUMP REPLACEMENT: H.P.State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Materia! and Procedure Approximate Depth <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 /> Home owner or licensed agent's signature certifies the following."I certify that in the performance of thework forwhich 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 /> I will all for rout Inspection prior to grouting and a final inspec ' <br /> Signed X 01 <br /> (Draw <br /> ),, <br /> Title.- Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASEI FOR DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: Date <br /> Phase 11 Grout Inspection <br /> Inspection By_ hase III Final Inspection �+ <br /> Date Inspection By Date <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH <br /> ❑ January 1 8 Received By January 31 ❑ July 7 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ( AMOUNT <br /> FEE g. ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by f DatrY Receipt No. Permit No, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES Issuance Date Mailed Delivered <br /> 9601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />