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7Applica' s IT •-roc si— I n submitted Properly Completed.Be Sure To Sign T 1Q pE�Ch#t?1.NfLi <br /> � <br /> PPLICATION <br /> FOR OFFICE USE: � k . <br /> (For Non- LaJ� terable, Rtalracable;Suspendable} P&WELL <br /> DEC 1IRONM' ENTAL HEALTH PERMIT NOV 24 1981 <br /> (COMPLETE IN TRIPLICATE) I , t Ir WATER QUALITY <br /> Application is hereby made toth 1�J1�6�qu1;t�ec'aU-IEa �Strictforapermittoconstructand/or install the work-herel I e 7hlsap Ic it its <br /> made in compliance with San Joa(i inrOoun't"y Gla J&J ci�l�. 1862 and the rules and regulations of the San Joaquin Locall a1l� &, iCf-�ECT <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address l'.. er�1 L°' City . <br /> Contractor's Name /� � r +License# Business Phone ����as <br /> Contractor's Address 6t, *' ' r Emergency Phon f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No C>3 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ; <br /> WELL CHLORINATI ❑ WELL 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 l 9^}" Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 13 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER. Other Inforrhiiticin, - <br /> ❑ GEOPHYSICAL Surface Seal installed By: <br /> PUMP INSTALLATION: Contractor <br /> ,Ty e of Pump H.P. a 3 <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 r j� <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, 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 /> -1 <br /> I will call for a Grout Inspection prior to grouting and a final inspection. r R <br /> pate ,>✓_!'a�3 41 <br /> Signed X . ��'12i��.�>>- -�• // etx1 Title: <br /> * " (Draw Plot Plan on Reverse ide) -r <br /> FOR DEPARTMENT USE ONLY <br /> p f <br /> PHASE I r � Date <br /> Application Accepted By <br /> Additional Comments: <br /> I <br /> PhaseJI Grout Inspection ase III Final Inspection <br /> Inspection By Date Inspection Byte � t?ate <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE '❑ 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 DU <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No.' Permit No Issuan a Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />