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� ly Jae,[Su��T�O}sl�T e pnceuvr+. <br /> _ Applications Will Se Processed When Submitted Properly P 15'r( <br /> FOR OFFICE USE: <br /> APPLICATI <br /> . _ (For Non-Transferable,Revoci�eSuspendable) P&WELL <br /> ENVIRONMENTAL HEALTH P&WI-6 1981 <br /> WATER QUALITY CA I � 1 I y,� ( ,,: ' <br /> (COMPLETE IN TRIPLICATE} twsvgndiforir?st'al{f7ewt rein described.This application is <br /> Application is hereby made to San Joaquin Local Health District fora permitto conss&�f ry�� �1 <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and r <br /> �a s° f ba uin Local Health District. <br /> City/Town } <br /> Exact Site Address 1 <br /> � - Phone .� <br /> Owner's Name City <br /> 00 J <br /> Address s Business Pho e � <br /> License f <br /> Contractor's Name - x �• , <br /> �4 r9 7 _ Emergency Pho e <br /> Contractor's Address n'''-�""` a <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> i� <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ AIR 13 <br /> r- <br /> WELL CHLORINATI N 13WELL ABANDONMENT ❑ OTHER 13PUMP INSTALLATION C3PUMP REPy <br /> REPLACEMENT LiPit Priv d <br /> Sewer nes Y <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Ss"&e Pit Other <br /> Sewage Disposal Field <br /> Property Line Private Domestic Well Public Domestic Well f <br /> 101 <br /> NTENDED USE s TYPE OF WELL x <br /> DUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing 4 <br /> OMESTIC/PRIVATE Gauge of Casing <br /> OMESTIC/PUBLIC 0 DRIVEN <br /> RRIGATION ❑ GRAVEL PRCK Depth of Grout SealATHODIC PROTECTION ❑ ROTARYType of Grcut <br /> ISPOSAL OTHER Other Information <br /> 1 $Iirface Seal Installs By: <br /> EOPHYSICAL �0P INSTALLATION: Contrac��r <br /> H.P. <br /> T �-of-Rrxrn <br /> PUMP REPLACEMENT: ❑ State Work Don <br /> PUMP REPAIR: ❑ State WorK^D,o. <br /> DESTRUCTION OF WELL: <br /> ell Diameter Approximate Depth <br /> �D cribs Material and Procedure � <br /> I hereby certify that I have preps d this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules re ulations of the San Joa uin Local Health Distri I. <br /> Home owner or licensed agent's signature certifies the followin :"I Certif�tb that <br /> to workmain the perio� n e on flaws of California." <br /> is issued, I shall not employ any person in such manner as to 1 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify khat in th performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of Ca�ifornia." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. T <br /> I Title: Date: <br /> F Signed X �- - .- <br /> - (Draw Plot Plan on Reverse Side) �K <br /> i FOR DEPARTMENT USE ONLY <br /> PHASE Imo. Date �r <br /> By <br /> Application Accepted Y <br /> Additional Comments: Phase III Final Inspection <br /> ` Pha II Grout Inspection_ ' <br /> Inspection By Date — <br /> Inspection By Date j <br /> 1 <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT El PER SITE El EACH ❑ January 5'&Received By January 31 ❑ July 1 S Receiv July 31 <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE `REMITTED AMOUNT <br /> a 5 - <br /> FEE } <br /> LESS <br /> PRORATION _ _ - <br /> PLUS <br /> PENALTY. <br /> OTHER I' - <br /> OTHER <br /> 32- <br /> Mailed Delivered .._ <br /> ' Receipt•No. Permit No. ..Issue a Date <br /> Received by Date 1601 E.HAZFLTON AVE.,P.O.BOK 2009 STOCKTON,CA 95201 <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTR PERMIT/SERVICES <br />