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Applications Will Be Processed When Submitted Properly lld er 6,s$,gRrh licaiion. <br /> FOR OFFICE USE: APPLICATI <br /> (For Non-Transferable-, Rev oca �$�auspendable) /1 <br /> ENVIRONMENTAL HEALTH P�73 0 1981 I'�1MP&WELL <br /> �-7'" WATER QUALITY �I —030--/-3 <br /> (COMPLETE IN TRIPLICATE). �(��/`�-- SAN ji,sl,� s iP j r, <br /> Application is herebymade to the San Joaquin Local Health District,fora ermittoconstru ( Inst I'it 1w, li116in described.This application is <br /> made in compliance with San In:�2 'n N .,18 p le.�.ul s an T tions�f 0 r }� u o trict. <br /> Exact Site Address , f +' City/Towna <br /> Owner's Name / 491A' J"'" � � ' Phone <br /> Address City <br /> zk 2—i 46 <br /> Contractor's Name` Ll „L,i�ease# mousiness P orgy <br /> Contractor's Address �' J Emergency Phone G <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No r n <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑. DESTRUCTION❑ V t <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ /rte <br /> REPLACEMENT❑ L1" <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 Domt_,. Well <br /> INTENDED USE TYPE OF WELL <br /> r C1 INDUSTRIAL ❑ CABLE TOOL Dia:of-Well Excavation- <br /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ OMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seat <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 4 <br /> PUMP INSTALLATION: Contractor W <br /> Type of Pump H.P. N <br /> PUMP REPLACEMENT: ❑ State Work Done 4 of <br /> ,�, / r 1 <br /> PUMP REPAIR: ✓ Mate Wor ne zt <br /> DESTRUCTION OF WELL: Well Dia ter <br /> Describe Mater' 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 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." <br /> tontr,,actorsub-conlr g signature certifies the following:" ertifyat in the performance of the work forwhich this. <br /> I emplo pe ons subject to workman's compen,ati laws o California." <br /> Inspecti n or to r g and a tinct inspectia . <br /> Signed X Title: Date: <br /> (Draw Plot Plan on R erse Side) <br /> i <br /> FOR DEPARTMENT USE ONLY, <br /> PHASE I <br /> Application Accepted 8y Date 431 1 <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 Final Inspection j <br /> Inspection By Date Inspection By , <br /> � -� pate t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE S REMId <br /> T' <br /> BASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS I <br /> PENALTY 1 <br /> OTHER <br /> OTHER <br /> 3 <br /> Received t)y Date Receipt No. Permit No. Is uance ate Y Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 7661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95241 <br /> - y .- A <br />