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Applications Will Be Processed When Submitted Properly Completej.tgtsuresTo Sign meAppllicaTtqw <br /> FOR OFFICE USE: APPLICATION "S t `tom � ✓�' <br /> (For Non-Transferable, Revocable,Suspe able) t:1a� <br /> p P&WELL <br /> ENVIRONMENTAL HEALTH PERMITf10 aid ulml, L +� <br /> T <br /> (COMPLETE IN TRIPLICATE) 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 Slam Joaquin County Ordinance No. 1862 and the rules and regulations of the San Jo uin Local alth District. <br /> Exact Site Address :at.� � �Y N City/Town /mak <br /> Owner's Name //, /,IC' Phone <br /> Address l S City <br /> Contractor's NameT c icense#�,�Business Phone <br /> Contractor's Address �r U 6 J� 10J Emergency Phon <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cess poot/See page Pit Other , p <br /> Property Line Private Domestic Well Public Domestic Well r <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> tA <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 <br /> Type of Pump SL' l3 M�>I S/�.� H.P. <br /> PUMP REPLACEMENT: PL State Work Done ✓ ,/,-- y <br /> PUMP REPAIR: ❑ State Work Done Gl� �� <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 /> 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, 1 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:"1 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 will Call,10 a Grnsp coon pr' r to outing and a final inspection. <br /> 74 <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ` 3 y <br /> Application Accepted By p Date / Y <br /> Additional Comments: <br /> Phaa 11 Grout Inspection Ph s III Final inspection <br /> Inspection By_ /" 7y Date Inspection By Date r <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 /> LA- <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered f <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMiT15ERViCES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />