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Applications Will Be Processed When Submitted Properly Completed.Be S e. 1,Sign4 ppIication. <br /> FOR OFFICE USE: APPLICAT�IQ_ N `{� <br /> h' (For Non-Transferable, Revocelbf�, Shce) p&WELL <br /> ENVIRONMENTAL HE: �H'PF� *111 i9 2 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 11 <br /> Application is hereby madetotheSanJoaquin Local Health District for a.permittoconstruct and/%itt <br /> rst�h�eN A�indescribed.Thisapplicationis <br /> f ia1 q, f�t t <br /> made in compliance with San Joaquin County Ordinance No. 7862 and the rules and ulatibnsft i�apRl, uin Local Health District, <br /> Exact Site Address 7 tty/ own . <br /> Owner's Name if ir;,. - Phone <br /> Address City <br /> Contractor's Name J,�rGN G� License# / <br /> ,��� �-2�� Business Phonexi <br /> Contractor's Address Pa2—. <br /> Emergency Phon <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 ❑ PUMP INSTALLATION ❑ PUMP REPAIR 13 <br /> REPLACEMENT❑ v)l <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy r' <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line _ _ Private Domestic Well Public Domestic Well <br /> INTENDED USE z r yea (TYPE OF WELL T �' ; _ - <br /> ❑ INDUSTRIAL ❑ CABLE TOOL" Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑1�OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> LU IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Y Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter R Approximate Depth <br /> Describe Material and Procedure <br /> I hereby certify that l,have. prepared this application and that-the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules acid 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 /> 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 /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X aw.4 7'n ' l Title: Date: . <br /> (Draw Plot Plan on Reverse Sid6 ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Ij " <br /> Application Accepted By ��'�"'-� �`-"""� C � Date to— <br /> Additional Comments: <br /> Phase It Grout Inspection ,_Phase III Final Ins ection <br /> Inspection By Date Inspection By '� J. Date �z f01L <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION PATE DATE REMITTED AMOUNT DUE CHECKED <br /> {, AMOUNT <br /> FEE 1Q <br /> LESS <br /> PRORATION <br /> PLUS - - <br /> PENALTY <br /> OTHER <br /> OTHER N <br /> Received by Date - Receipt No. Permit No Issua ce Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />