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s Applic ti <br /> Applications Will 8e Processed When Submitted r <br /> openy APPLICATION <br /> FOR OFFICE USE: n-Transferable, Revocable, Susp� able) �} 4 IQ82 &WELL <br /> (For No - <br /> . ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY SAN JO, ',N LOCAL <br /> (COMPLETE IN TRIPLICATE) A la 4TAoP14TXQJ;cribed.This application is <br /> Application is hereby m trr��e an Joaquin Local Health Districtfora permittO construct and/o I <br /> made in compliance wit an.lquin Caunty Ordinance No. 1862 and the rules and regulations City/Town Joaquin Local <br /> District. <br /> Exact Site Address_�� <br /> r �/LT71.7ei4' .�� Phone . 0 <br /> 'I Owner's <br /> Name City <br /> t Address r License# usiness Phone <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ©ESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ —4- Pit Privy <br /> Tank �— <br /> Sewer Lines Other —� <br /> DISTANCE TO NEAREST: Septic: {�- Cesspool/Seepage Pit <br /> • Sewage Disposal Field �blic Domestic Well <br /> Property Line�XQ-Private Domestic Well�5Q <br /> t TYPE OF WELL <br /> INTENDED USE Dia, <br /> INDUSTRIAL <br /> of Well Excavation <br /> INDUSTRIAL CABLE TOOL �� <br /> ❑ DRILLED Dia. of Well Casing O <br /> k ❑ Gauge of Casing <br /> DOMESTIC/PRIVATE _ <br /> ❑ DRIVEN <br /> ❑ DOMESTIC/PUBLIC Depth of Grout Seal <br /> 11 IRRIGATION El GRAVEL PACK .PJI.GT <br /> ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION Other Information <br /> IJ DISPOSAL ❑ OTHER <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> tractor ` <br /> r PUMP INSTALLATION: Conf H.P. <br /> Type of Pump - <br /> PUMP REPLACEMENT: <br /> ❑ State Work Done t <br /> PUMP REPAIR: ❑ State Work Done Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> I hereby certify that 1 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 /> Homeowner or licensed agent's signature certifies the following:"l certify that in the performancem 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 t California." Q <br /> r g:" y <br /> FContractor'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 /> I wil all for a Grout Inspection p for to growling and a final inspection. Date: <br /> Title: <br /> Signed X (praw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: Phage III Final Inspection <br /> ase I rout pection W,,f/r Date <br /> f / Date l �t Inspection By. „ s� <br /> Inspection By j <br /> ❑ AER SITE - El EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT - CHECKED <br /> ' BILLING REMITTANCE AMOUNT DUE <br /> BASE .j EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE ► J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER i1 <br /> Receipt-Nu. Permit No.. <br /> I want Date Mailed Delivered <br /> Received by � Date _ 1501 E.HAZELTON AVE,P.O.Box 2009 STOCKTON,CA 95201 <br /> f APPLICANT—RETURN ALL.COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />