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r Applications Will Be Processed When Submitted ProperlyCompleted. <br /> I APPLICATION <br /> FOR OFFICE USE: <br /> i (Far Non-Transferable, Revocable, Suspendable) <br /> PL1MI'&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> f ' WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and"regulations of the San Joaquin Local Health District. <br /> City/Town <br /> Exact Site Address_�� �_. M - <br /> Lewis Fra er Phone 8.�b--�-8b8 <br /> Owner's Name T'r�nt <br /> Clover Rd . city <br /> Address 11 <br /> Contractor's Name " <br /> License#_29a813- Business Phone <br /> Contractor's Address Emergency Phone _5iL5- <br /> Is Certi€irate of Workman's Compensation Insurance on File With SJLHD? Yes�— <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 11 RECONDITION 11 DESTRUCTION <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DI57ANGE TO NEAREST: Septic Tank _I_M <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED"USIEu TYPE OF WELL <br /> 13 INDUSTRIAL <br /> 11CABLE TOOL Dia. of Well Excavation—_�_4ri <br /> - rt - <br /> DOMESTIC/PRIVATE DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> 50 <br /> { ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> i <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> t <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 /> k home owner or licensed agent's signature certifies the following:1 certify that in the performance of the work for which this permit <br /> r is'issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> k <br /> Contractor's hiring orsub-contracting signature certifies the following:"l 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 /> 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X <br /> Title: s Date: <br /> ( raw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE 1 , y'��l �ll � Qri ka8-� <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> e II G ro_4 Inspection Phase III Fi al In ection <br /> Inspection By <br /> Date - �� Inspection By ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Il PER SITE ❑ EACH ❑ January 1 &Received By.January 31 ❑ July 1 &Rec6.v REMyI July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE f <br /> LESS r/ <br /> i- PRORATION <br /> 4' PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 41 1B l �o S 1t�5� <br /> Received by <br /> Dale Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />