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Applications Will Be Processed When Submitted Properiy Completed. Be Sure To!S Thbirriltion.1981 <br /> FOR OFFICE USE: APPLICATION [J tt77 �I <br /> (For Non-Transferable, Revocable,Suspendable) UMI'p WELL <br /> SA I� .} .;w, LOCAL ` <br /> ENVIRONMENTAL HEALTH PERMIT HLALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY , <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permit to construct and/or install thework 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 /> Exact Site Address Cot) l�6 U)• 4C. aoT)I(8I -S-,VD&V _ City/Town <br /> � k,0V; = <br /> J <br /> Owner's Name ��. L eJ?n0&4 Ofd-��-� ( Phone ` (Q14_4? <br /> Address '';a° - -57 r7fity <br /> Contractor's Name Icense# usiness Phone- <br /> _4919L Y <br /> Contractor's Address �, �" 0AL-J -- "Emergency Phone 02 <br /> f Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 7i_ No r y— <br /> TYPE OF WORK (CHECK): NEW WELL❑" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATIOWO WELL ABANDONMENT ❑ " OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> � REPLACEMENT ~,"- <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property,Line Private Domestic Well Public Domestic Well <br /> 1 INTENDED USE TYPE OF WELL <br /> NDUST RIAL ❑ CABLE TOOL Dia. of Well Excavation - <br /> ❑ DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> I OMESTIC/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 q Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> PUMP REPLACEMENT: e Work DoneCf ��, <br /> PUMP REPAIR: ' ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth a <br /> Describe Material and Procedure <br /> t � <br /> hereby certify that I have prepared this application and that the work will be done inaccordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District.. ' s <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 compensatiori 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 or a Grout Inspection rior tog uting and?a final inspecilon. <br /> Signed XTitle: Date: <br /> (Draw 01ot Plan on Reverse Side) <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> \" _..... <br /> Application.Accepted By: -- Date <br /> Additional Comments: <br /> Phase II Grout Inspection Ph a III Final Inspection <br /> Inspection By Date Inspection B� pate ZAI <br /> ` <br /> Fee Is Due: C1 "ANNUALLY ❑ PER bNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ! <br /> PLUS - <br /> PENALTY <br /> OTHER } <br /> OTHER <br /> --Received by Date Receipt No, Permit-No. - lssuAnc6 D to .1mailed Delivered --,. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES _ 1601 E.HAZELTON.AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />