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umppp <br /> cation. <br /> Applications Will Be Processed When Submitted Properly Comlei dHe 19 <br /> FOR OFFICE USE: APPLIC !(For Nan-Transferable, Rev . lTe uspendable) &WELL <br /> ' ENVIRONMENTAL H <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) � th rein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District permit co tW alg 4 p� <br /> J)b%%E49 quin Local Health District. <br /> made in compliance with San Joa in County Ordinance No. 1862 and the rules an fq�� o <br /> C�i�/7 . q YI City/Town <br /> Exact Site Address rt <br /> Phone <br /> Owner's Name City 1i� <br /> Address ®" FOR <br /> Contractor's Name License# 16��47�_—_ Business Phone <br /> Contractor's Address �� ��—��� rpt . 9�- - Emergency Phone <br /> I} 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No " <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 11PUMP INSTALLATION ❑' PUMP REPAIR❑ <br /> REPLACEMENT❑ r <br /> Sewer tines � Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Other <br /> Sewage Disposal Field Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavatidn <br /> ❑ OMESTIC/PRIVATE 11 DRILLED <br /> Dia. of Well Casing v <br /> LTJ DOMESTIC/PUBLIC El DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H.P. <br /> Ty e of Pump <br /> PUMP REPLACEMENT:. State Work Done <br /> PUMP REPAIR: -:' <br /> ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter <br /> 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. <br /> Homeowner 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 /> 4 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 /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Title: Date: z — <br /> Signed X <br /> (Draw Plot Plan on Reverse Si e) <br /> Ann FOR DEPARTMENT USE ONLY <br /> PHASE 1 `�/ `�✓\!�� �1 Date d <br /> Application Accepted By <br /> Aa� <br /> Additional Comments: <br /> Phase II Grout Inspection Phase ll Final Inspection `Q v <br /> �n � � Date Inspection By Date <br /> Inspection By ` ` • <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ' ❑ PER SITE ❑ EACH ❑ January i &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE 1`� <br /> LESS <br /> PRORATION - - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by <br /> 'Receipt No. -'Permit No. -. -- Issuanc Date Mailed Delivered <br /> � -Date �� ' <br /> 1801 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> .,APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES — <br />