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Applications WIII Be Processed When Submitted Properly C 1 f Inge cation. <br /> FOR OFFICE USE: APPLICA 'y <br /> Yin => (For Non-Transferable, Revocable spendable) p &WELL <br /> ENVIRONMENTAL HEALTH'PERNG 2 4 1Z <br /> (COMPLETE IWTRIPLICATE) WATER QUALITY <br /> Appiicationishereby madetothe San JoaquinLocal Health Districtforapermit toconstru$&kd/�rin'stgfitt'ret++ro�=Alm described.This application is <br /> &6,, per►, <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the,rules and regilla S, fhe Sail t o Local Health District. <br /> Exact Site Address City/Town <br /> Owner's Name ''A,6 hPhone <br /> Address City <br /> Contractor's Name License# 14 -137_2 Business Phone n <br /> Contractor's Address A. .z - Emergency Phone '.- <br /> `, r <br /> Is Certificate of Workman's Compensation Ins ance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELT. ABANDONMENT ❑ OTHER 1:1 PUMP INSTALLATION� P,UMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy d � +• .f <br /> Sewage Disposal Field Cesspool/Seepage Pit � nth`. . <br /> Property Line Private Domestic Well Public°Domestic Well <br /> INTENDED USE TYPE OF WELLn + <br /> ❑,4NDUSTRIAL <br /> [ 11 CABLE TOOL Dia. of Well Excavation <br /> � a i <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing - '• - G I '' <br /> ❑ DOMESTIC/PUBLIC DRIVEN Gauge of Casing <br /> 1 . t° <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal F <br /> 11 CATHODIC PROTECTION ❑✓ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 0 GEOPHYSICAL- Surface Seal Installed By: '- <br /> PUMP INSTALLATION: Contractor <br /> ;_ <br /> Type of Pump H.P. -1 <br /> PUMP REPLACEMENT: Y State Work Done F <br /> PUMP REPAIR: T• ❑ state Work Done ` ` 3 w ' <br /> DESTRUCTION OF WELL: Well Diameter Approximate`De,pth f' 7 <br /> Describe Material and Procedure 1 <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 /> 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." 1 <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certifythat 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 (A-4'- ITn-o Title: k Date: f <br /> (Draw Plot Plan on Revere <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /4000) <br /> Application Accepted By Date <br /> Additional Comm <br /> se rout i <br /> :nspection O r <br /> 4ep nInspectionDatInspection Byo A <br /> Fee IS DIIB] ❑ NUALLY ❑ RER UNIT` `© PER SITE El EACH ❑ January 1 & e ved By January 31 ❑ July t 8 Received By July 31 _ <br /> r REMIT <br /> BASE EXPLANATION BILLING ,REMITTANCE $ { <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �w`�,. AMOUNT "# <br /> Y C7 <br /> FEE <br /> LESS <br /> PRORATION ! <br /> PLUS r <br /> PENALTY i <br /> OTHER <br /> OTHER <br /> Received tq Date Receipt No, Permit No. Is ance Dald Mailed -- Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMtTISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />