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Applications Will Be Processed When Submitted Properly Completed. B b`�I a nLt0e1ApIVicakdn, <br /> _ APPLICATION LJ �1�I1�1 <br /> FOR-OFFICE USE: <br /> -OCT(For Non-Transferable, Revocable, Suspenda11 1T <br /> ENVIRONMENTAL HEALTH PERMIT "'"'P 8`WELL <br /> UIN LOCAL N <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN ,OAQ <br /> Di1 I`` <br /> i Application is hereby made to the San Joaquin Local Health Districtforapermiktoconstruct and/or install N�y�rJcl�re4n ���fi� .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 /> I Exact Site Address 6 / City/Town ej <br /> Owner's Name <br /> Phone <br /> Address d City <br /> Contractor's Name License # GO Business Phone ' -'/Y/G <br /> i Contractor's Address �— Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHO? Yes t/ No : <br /> TYPE OF WORK (CHECK): NEW WELL (DEEPEN ❑ RECONDITION El DESTRUCTION❑ <br /> WELL,.CHJ6RINATION ❑ WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ + <br /> I REPLACEMENT. �c <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy Q <br /> ! <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <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 /> V <br /> MESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> RIGATION ❑ 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 /> Type of Pump '�- H.P. 7S <br /> PUMP REPLACEMENT: State Work D�oe ��� <br /> PUMP REPAIR: ❑ State Work Dane <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> 1. 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 /> i <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 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 forwhichthis� <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California."d). <br /> c <br /> I will c 11 for a Gr t Inspection prior to grouting and a final inspection. 5- <br /> Signed X Title: �. � �+--�� Date: lO 2 <br /> (Draw Plot Plan on Reverse Side) <br /> FO DEPART ENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection Pha Fina! Spec tion ♦ <br /> Inspection By Date Inspection By � Date 1 is <br /> I•. Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> EASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED dr AMOUNT <br /> FEE XJ l2 <br /> ` LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> :77 9-11 S7 .1061�.J?� - <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />