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Applications Will Be Processed When Submitted Properly CompiTik5F <br /> r�jTo4Sign Th lication. <br /> FaR oF>=SCE USE: APPLICATI ,�9 <br /> w- (For Non-Transferable, Revoca u endable) 9 <br /> 01 <br /> ENVIRONMENTAL HEAL ER N �Or,N\- PUMP&WALL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY PAQV���}}15[R1G� <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct aswCCI ta1(1ii orkherein described.This applicationis <br /> made in compliance with San Joaquin County Or finance No. 1862 and the rules and regukati�l9- Ehe San aqui Local Health District. ,4 <br /> Exact Site Address City/Town ri <br /> Owner's Name- �J� Phone 1-' G ��� 23-38 j <br /> Address City <br /> Contractot s Name r License#J6. , 73 Business Phoned <br /> Contractor's Address 6. If. Emergency Phone ' <br /> Is Certificate of Workman's Compensation Incur nce on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑' RECONDITION El DESTRUCTION❑ <br /> WELL CHLORINATION El WELL ABANDONMENT I ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENTP­� I r <br /> 1. <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/.Seepage Pit Other \r <br /> Property Line Private Domestic Well Public Domestic Well O <br /> INTENDED USE TYPE OF WELL - <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation y <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 �A <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL urface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H"P. <br /> PUMP REPLACEMENT: G�`4tate Work Done T� ( <br /> PUMP REPAIR: ❑.State Work Done <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" f <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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> .Lf _ - <br /> I w' all t r a Grout I pection prior to routing and a sinal inection. <br /> Signed X Title:7 — Date: <br /> V4&raw Plot Plan on Reve&Side) <br /> FOR DEPARTMENT USE ONLY."" <br /> PHASEI <br /> Application Accepted By &Iq Date 3/ <br /> Additional Comments: <br /> Phase II Grout Inspection h se I11 Final InspectioIn <br /> Inspection By Date Inspection <br /> By <br /> �• Date A t 1 <br /> t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE [Jr 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 A <br /> LESS x - <br /> S <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> � s <br /> OTHER <br /> OTHER ! <br /> s>) t <br /> 74 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> r <br />