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Applications Will Be Processed When Submitted Properly Completed.Be yr %To'@jgnTheAPPRCauon. - <br /> OFFICE USE: <br /> FOR APPLICATION <br />' FORr, n' <br /> (For Non-Transferable, Revocable, S d e) %O UhAP&WELL <br /> Q ENVIRONMENTAL HEALTH IT p�G �.� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �.fl� <br /> Application is hereby made to the San Joaquin Local Health Districtforapermittoconstruct and/or i th�vLo�i\hereindescribed.This application is <br /> made in compliance with San Joaquin No. 1882 and the rules and regulations t�n Jo uin Local Health District. <br /> Exact Site Address S�Z I �'- � City/Town �� $ <br /> Owner's Name Phone <br /> ? — City # <br /> Address — �- <br /> Contractor's Name d-.S License# 7S Business Phone , <br /> Contractor's Address CJ Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on Ile With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ G <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ UMP INSTALLATION UMP REPAIR❑ F <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy �(1} <br /> Sewage Disposal Field Cesspool/Seepage it _ Other <br /> Property Line f Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Q <br /> ❑ DOMESTIC/PUBLIC ❑ 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 /> ❑ GEOPHY Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor S <br /> I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: -State Work Done <br /> PUMP REPAIR: 0]State Work Done <br /> E <br /> DESTRUCTION OF WELL: Tipi'scribe <br /> l Diameter Approximate Depth # <br /> Material andProcedure <br /> I hereby certify that I hale 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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." P <br /> 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 /> t <br /> I will tali for a Gr butt Inspection prior to grouting and a final inspection. / <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Ide) <br /> F9f DEPARTMENT USE ONLY ' <br /> i <br /> PHASE <br /> Application Accepted By Dat <br /> Additional Comments: <br /> ''iPha t Final I ped <br /> Phase It Grout Inspection ction � 7 <br /> Inspection By Date_ Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> (—J1 DATE r DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY ,I <br /> r OTHER sf , <br /> t <br /> OTHER <br /> 1� <br /> 7 g <br /> Received by - Date-- Receipt No. Permit No. - Issuance Date Mailed Oe$ivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES®y[ 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> V t <br />