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Applications Will Be Processed When Submitted Properly C. leted. �aSure o`6n a ication. y� { <br /> FOR OFFICE USE: APPLICATION K< " <br /> � <br /> f.. (For Non-Tra sn ferable, RevocabSUspendable) P &WELL <br /> G } ENVIRONMENTAL HEALTH PEROU? 2 a W2 { <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY.. p �,�s,t� <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to constr66 I d/or-install't4wVky�trel'1L described.This application is <br /> made in compliance with San Joaquin County rdinance Nv 6 and the_rules and re td�' oth�5al1 in L al Health District. <br /> Exact Site Address J , 4` City/Town <br /> Owner's Name �'���7 Phone 3 ?J <br /> Address jc-r � �, ,r° City' <br /> Contractor's Name License#�[ ,,v 2 Business Phone <br /> Contractor's Address l �� / 'Emergency Phone 2 <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No (� <br /> TYPE OF WORK (CHECK): NEW-WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 1 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 3— f V <br /> DISTANCE TO NEAREST: Septic Tank ` ' Sewer Lines Pit Privy <br /> Sewage Disposal Field~` Cesspool/Seepage Pit _ Other v ; <br /> "Property Line 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 <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 /> ❑ GEOPHYSICAL i S face Seal Install d By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> b-3- tate <br /> � t <br /> PUMP REPLACEMENT: L� State Work Done <br /> PUMP REPAIR: © State Work Done I <br /> DESTRUCTION OF WELL: Well Diameter' <br /> Approximate Depth 1 <br /> jescribe=M eri°alFand�Procedure. Y �^ ; <br /> hereby certify that I have prepared this application and that the work will be done iri'accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Z <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." . <br /> I w all t a Grout I ction prior to 4outing and a final inspection. • <br /> Signed X Itle: Date: <br /> (Draw Plot Plan on Reverse/Side) a` <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I ,rj. <br /> Application Accepted By Date - - <br /> Additional Comments: <br /> Phase II GrogUinspection Phase III Final Inspection <br /> Inspection By n ( Date Inspection By Date <br /> i <br /> Fee IS Due: ❑ ANNUALLY C1 PER UNIT ❑ PER SITE El EACH ❑ January 1 &'Received By January 31 ❑ July 1 &Received 8y July 31 <br /> BILLING REMITTANCE $. REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> t DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS > <br /> PRORATION <br /> PLUS , <br /> PENALTY t <br /> OTHER <br /> OTHER <br /> 6 � <br /> Received by Date - Receipt No:- Permit No.- + I ante D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201, t f� <br />