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Applications Will Be Processed When Submitted ProperlyCompleted. tiesure IoSign irteAppitcauvn. <br /> FOR OFF-XE USE: APPLICATION ` <br /> -„ (For Non-Transferable, Revocable,Suspendable) i Pip&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) : „--- <br /> WATER QUALITY <br /> Application is hereby madetotT a San Joaqiuin Local Health District fora permit to construct and/or install the work.herein described.This application is <br /> C made in compliance wit�l San J aquin county Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address I ~ w City/Town <br /> Phone <br /> Owner's Name <br /> t- <br /> Address City _ <br /> Contractor's Narne1R' 5 �11� License# c1 1 Business Phone <br /> Contractor's Address ��� p2 1AoL\ iNy_ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD9 Yes No (` <br /> I TYPE OF WORK (CHECK): NEW WELLS DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ �, <br /> REPLACEMENT❑ .k <br /> DISTANCE TO NEAREST: Septic Tank '11,00 T Sewer Lines Pit Privy <br /> Sewage 6isposal Field n0~t Cesspool/Seepage Pit Other <br /> Property Line . Private Domestic Well Public Domestic Well <br /> INTENDED USE x TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ® DOMESTIC/PRIVATE ® DRILLEDq Dia. of Well Casing <br /> 11 13DOMESTIC/PUBLIC ❑,DRIVEN , Gauge of Casing <br /> ❑ IRRIGATIONGRAVEL'PACK Depth of Grout Seal <br /> I <br /> 11 CATHODIC PROTECTION r ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed Bye ,D RSl P <br /> PUMP INSTALLATION: Contractor <br /> i Type of Pump H.P. <br /> k PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> FDescribe Material and Procedure <br /> I orharjeby certify that i have prepared this application and that the work will be done in accordance with San Joaquin County <br /> .. <br /> _. dinances, 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 vv <br /> 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:"I certify that in the per of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: U 3 Dater C601 (Draw Plot Plan on Reverse Side) { <br /> F <br /> i 1 FOR DEPARTMENT USE ONLY <br /> PHASE I I <br /> F. - — Date <br /> Application Accepted By_-�-y <br /> �s.(�� ��-�`� <br /> Additional Comm'ents:' <br /> 6 P e II Grout In ection 111 Final 1 colon <br /> Inspection Bye e �" �� Inspection By Z/ 1-�3".Fd <br /> �M <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 F] July i &Received By REMlTu1y 33 <br /> ' BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> BASE EXPLANATION DATE DATE I+. REMITTED AMOUNT <br /> FEE - <br /> I LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> Received by - ate Receipt No. Permit No. -Issuance Date Mailed Delivered <br /> r APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />