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Applications Will Be Processed WhenSubmitted PropenyC.ompielicu. oe ­ury au-d­ <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Re o ;S n [DUMP&WEtL <br /> R N MET i P+�Z+�JJER <br /> ENV! O <br /> (COMPLETE IN TRIPLICATE) <br /> A fRR UALITY �9 <br /> Application is hereby made to the San Joaquin Local Health Distri permi eCcckstrun and/orri tall the work herein described.This application is <br /> made in compliance wit _San Jo n Count Or inance No. 18 the es and re I IQpre he San Joaquin Loca Balt District. <br /> Exact Site Address 1� y c� / own 1 �" i <br /> Owner's Name L •E V I,9�S Pct �� Phone ..�`��,s/ -..�� <br /> tj City—. r � t <br /> Address Licens <br /> ( Busines Phone <br /> Contractor's Name y1,rDf2���Sy <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❑ DESTRUCTION❑ -A <br /> WELL CHLORINATION 11WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ 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 <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 ❑ 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 \J <br /> Type of Pump H.P. L1 <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: tate Work Done Q <br /> DESTRUCTION OF WELL: Well Diameter - Approximateepth <br /> Describe Material and Procedure <br /> 1 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 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;' ertify that in the performance of the work forwhich this <br /> permit is d, I shall employ persons subject to workman's com a ation laws of California." <br /> w r Grout spect on prior to grouting and a final ins p ion. t> <br /> � <br /> Signed X Ti Date: <br /> h_7 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR EPARTMENT USE ONLY <br /> PHASE I dr <br /> Application Accepted By a — Date <br /> Additional Comments: <br /> Phase U Grout Inspection 1a a III Fin I Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 77 1 '7� <br /> Received by Date Receipt No. Permit No. Issuance Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CA 95201 <br />