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—Appliedtions Will Be Processed When SubAmPPLiCATIONr <br /> FOR OFFICE USE: (Fo?Non-Transferable,Revocable, Suspendable) p&WELL <br /> SpN j ti L",IC-T <br /> ENVIRONMENTAL HEALTH PERMIT �EA�TH DIS�R <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> ' hereby madeto the San Joaquin Local Health Districtfor a permit to construct and lor install work herein described.This application Is <br /> p.pplication Is y StOCktOn <br /> a Rd. City/Town <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> 4' 00 E. Mariposa qFt o 44 <br /> Exact Site Address Phone <br /> Eugenia Murchison oc on, <br /> 11 <br /> Owner's Name +��� 1 OS • City 2 2 1 <br /> usnes$ Phone <br /> Address Oho 0,In License#�� X63_3002 <br /> Contractor's Name One . Emergency Phone <br /> X No <br /> ;✓ontractar's Address <br /> Is Certificate of Work ensation insurance on File With SJLHD? Yes DESTRUCT[ONO <br /> ' TYPE OF WORK (CHECK): NWELL NEW WELL DEEPEN [] RECONDITION <br /> K (CH 13ABANDONMENT OTHER ❑ PUMP INSTALLATION❑ PU <br /> WELL CHLORINATIONMP REPAIR❑ <br /> Pit Privy <br /> REPLACEMENTS <br /> Sewer Lines Other <br /> ,I DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well , <br /> Property Line Private Domestic Wel; <br /> INTENDED USE TYPE OF WELL_ ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> 11DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION 1:1 ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION ❑ OTHER Other Information <br /> 13DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL Contractor H.P. <br /> PUMP INSTALLATION: <br /> Type of Pump4 <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: <br /> 13 State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> 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 /> ordinances, state laws, and rules and regulations of the San Joaquin Local Hearth District. compensation laws of Cai'rfornia." <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance the work forwhof Cali permit O <br /> is issued, I shall not employ any person in such manner as to become subjecI certify that into theperform nce of the work for which this v <br /> Contractor's hiring or sub-contractingsignature <br /> subject to workman's <br /> compensation laws of California." [7 <br /> permit is issued, I shall employ p <br /> I wi all for a Grou sp tion pno to grouting and a final inspection. Date: <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> ���Ph�ase <br /> DatePHASE 1 �Application Accepted ByAdditional Comments: �Finlspection <br /> Phase II Grout Inspection Date <br /> Date Inspection By <br /> Inspection By Jul 1 &Received By July 31 <br /> ❑ EACH ❑ January 1 &Received By January 31 y REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE $ AMOUNT DUE CHECKED <br /> BILLING REMY7TANCE EMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE R ! <br /> FEE <br /> }W <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receipt No Permi[No. <br /> lssu nce Dat Mailed <br /> E Received by - Date 16U1 E.HAZELTON AYE.,P.O.Box 2009 �STPCKTON X95241 <br /> -- _ppPLIGANT�RETURN ALL COPIES TO: ENYIRONMENTAL_HEALTH PERMITIS€RVICES <br />