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Applicatlona ..,It Be Procvssad When Submitted PrOperiy Completed.Be Sure To Sign The APPlicalfon. <br /> _FOR OFFICE USE: APPLICATION <br /> -- - (For Non•Tranglerable,Revocable,Susoendable)DaPmWwELL--- ENVIAONM ENTAL HEALTH PERMIT <br /> x (COMPLETE IN TRIPLICATE) WATER QpAIiITY <br /> vr. AppllCationisherebymadetotheSanJoaquinLocalHeahnDistrictforapermittoconstructand/or install the work herein de <br /> made in compliance with San Joaquin Cou �y�pr�d�irtance No, 1862 and the rules and regulations of the San oaquin Local Health District. <br /> p scribed.This application is <br /> Exact Site Address �CO�]_ <br /> -- -- <br /> OnW_ City/Town_1 �� <br /> wer's Name <br /> } Address _?- z - ' Phone <br /> r Contractor's Name _ City --•-��- � � „� <br /> r censeR <br /> H Contractor's Address _ Business Phone <br /> -- _mergency Phone <br /> Is Certificate Of Workman's Compensation Insurance on File Wi'," <br /> Yes No <br /> t. TYPE OF WORK(CHECK): NEW WELL 11DEEPEN❑ "ECONDITION❑ <br /> WELL CHLORINATION EJ WELL ABANDONMENT J�+ DESTRUCTION❑ <br /> i Y? REPLACEMENT© OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 11 � <br /> DISTANCE TO NEAREST: Septic Tank <br /> _ _ Sewer Lines <br /> - Pit Privy Ctl <br /> Sewago Disposal Field_ Cesspooi/Seepage Pit <br /> Property Line private Domestic Well Public DOther j <br /> a INTENDED USE --—_ Domestic Well,` - <br /> TYPE OF WELL <br /> ❑ <br /> INDUSTRIAL ❑ CABLE TOOL <br /> ❑ DOMESTIC/PRIVATE Dia.o1 Well Excavation- <br /> ❑ DRILLED <br /> u- Dia. Casing DOMESTIC/PUSLIC DRIV=N Gauge of Casing <br /> ® IRRIGATION ❑ GRAVEL PACK <br /> a; ❑ CATHODIC PROTECTION 13 Depth of GroSeal <br /> ROTARY Type of Grout.^• <br /> y� ❑ DISPOSAL ❑ OTHER 4 <br /> ❑ GEOPHYSICAL — Other Information_ — <br /> `° r' Surface Seal Installed By: <br /> hr PUMP INSTALLATION: <br /> Contractor• ,. . .a.� <br /> Typ?of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done — H.P. <br /> ` PUMP REPAIR: - - G <br /> 9 ❑ State Work Done _ <br /> DESTRUCTION OF WELL: Well Diameter__,„_T, �+! <br /> Approximate Depth <br /> Describe Material and Procedure <br /> a7R 14, <br /> I hereby certify that i nave prepared this application and that the work Wit be done in accordance with San Joaquin,County <br /> ordinances,state laws,and rules and regulations of the San Joaquin Loca!Health Di-ri <br /> 4 Homeowner or licensed agent's signature certifies the followin :'•Icertif th 't Gt, <br /> 9 certifythat in Ina performance of the work for which[his permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California. F <br /> Contractors hiring orsub-contracting signature certifies the fo"owing:"I certify that in the performance of ihework forwhichlhis <br /> permit is issued. I shall employ persons subject fo workman's compensation laws of California” <br /> �1--�will ACall for a,Grout Inspection prior to grouting and a final inspection. <br /> * 4, <br /> Signed X <br /> Title: �N Date: <br /> �. G. <br /> Zan <br /> ?iot Plan on R0v e.5 Side} J/ <br /> i <br /> PASE f FOR DEPARTMENT USE ONLY y <br /> H <br /> r Application Accepted By Date <br /> Additional Comments:---._______ — <br /> Phase II Great inspection - _- � -- "�- —••- - <br /> B 1tJ ry�\ Phase IiI Final Inspection <br /> Inspection <br /> o- y- -- 1 _ Date inspection By�L`_;L_}_ Date <br /> �i <br /> Fee Is Due:❑ ANNUM 4.Y PEA UNJT C1rEn EAC <br /> SITE ❑ r1 w <br /> »--- - - __ ❑ J��u ary t d necped tfY January 3F w <br /> ❑July 1 6 neceed By July 31 <br /> `t BASE 'IT Eh�LANi;TION BIL LILAC _I AeMiTTANCE i 1 .. �•FEMiT <br /> DATE N DATE .AMOUNT OUE <br /> i nL+nrTTEp CHECKED <br /> . - VEE ' 1 --I. -- .__. _. __ ._ T ---.._^—_ ,,.y_AMOUMT <br /> 1` LESS - <br /> nOAA <br /> PLUS, <br /> L1 <br /> ,,y. r't•rml <br /> rssua�lce Oatc 14legnrj p¢i,yr,� <br /> {'} AflPUCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMMSERVICES 16p1 E,HAZELTON AVE..PO Boa ZM STOCKTON.CA.1- <br /> T <br />