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Applications Will Be Processed WhenSubmitted Properlycomplete sure IoAUGign IreneAppncatum-- <br /> FOR OFFICE USE: APPLICATION G 3 0 1979 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> N J0,4Q�f N LOM <br /> &WELL <br /> ENVIRONMENTAL HEALTH PERNVIH�ALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in cq l e with San oa Co ty Ordin ce No. 862 and the rules an regulations of the S .gg uin Local Distrlc . <br /> Exact Site(�Jdre per` � �� y1` City/Town �9''.•JJ � �� f <br /> Owner's Name <br /> Phone <br /> L City <br /> Address <br /> Contractor's Nam" 2J License#� �/j Business Phone <br /> ���yl ST_Emergency <br /> Contractor's Address 9 Y Phone � <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION UMP REPAIR Vs <br /> REPLACEMENT❑ 1 <br /> i <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other I <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 /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal l <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information O <br /> 11 GEOPHYSICAL �z1 Surface Seal I stalled By: <br /> PUMP INSTALLATION: L-�� ContractorL f �' �U <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure t— <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 /> i, <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work fpr which this <br /> permit is iss all employ pe subject to workman's compensation laws of California." <br /> I will call 0 1 ection p or to grouting and a final inspec <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> OR DEPARTM NT USE ONLY <br /> PHASE t <br /> Application Accepted By Date 9 <br /> t Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Dagen Inspection By 4 <br /> Date ��2 Z <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT- In PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> ;BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS = <br /> PENALTY <br /> OTHER <br /> OTHER y; <br /> �] — 3 -7 <br /> Received by Date Receipt No.. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES r 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 <br />