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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The ARIp <br /> 1.0' "OFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PU WELL <br /> ENVIRONMENTAL HEALTH`PERMIT DEC 7 1981 <br /> COMPLETE IN TRIPLICATE WATER QUALITY <br /> Application is hereby made to the SanJoaquinLoc HealthDistrictfor rmit oconstructand/or install the work herein d i i ed�(TTnK?6.�p�ical+Brr <br /> made in compliance wi;hryJuindnty ria o. 18 2( L; r1d regulations of the Sa� Locy� 13 3trTRICT <br /> Exact Site Address / CJ City/Town <br /> Owner`s Nam ' '" �`� �~ "'• Phone <br /> Address L 70 <br /> City r <br /> Contractor's Name f 1 icense# Bus' ss Phone <br /> Contractor's Address -T771 Emergency Phone r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No _ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ ---RECONDITION❑ i DESTRUCTION.11_',+a " 1 <br /> WELL CHLORINATION ❑ 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 Othery" <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE - TYPE OF WELL <br /> t <br /> NDUSTR IAL ❑ CABLE TOOL Dia. of Well Excavation <br /> I OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> t DOMESTIC/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 Surface Seal Installed By: <br /> I PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT/: . .❑ State Work Done <br /> PUMP REPAIR: T/ ❑ State Work Done 1 0 4 ' <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth a <br /> Describe Material and Procedure <br /> hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> j ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner 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 nota ploy any person in such manner as to become subject to workman's compensation laws of California." <br /> r <br /> € Contractor's hiri sub-contract' nature certifies the following:"I ce at in the performance of the work forwhich this <br /> permit ' shall employ ersons s bject to workman's compensa ' aws of California." T { <br /> - I I c 1 spection Nor to outing and a final inspection. <br /> 00 <br /> Signed X Title: Date) <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date\A <br /> Additional Comments: <br /> Phase II Grout Inspection it epPhase III Final I peclion <br /> Inspection By - K\No Date Inspection By Q 7 Date <br /> ' Fee IS Due: ❑ ANNUALLY `" E]'PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> r - <br /> REMIT <br /> BILLING REMITTANCE.- $ <br /> BASE EXPLANATION DATE DATE REMITTED; _ AMOUNT DUE' CHECKED <br /> AMOUNT <br /> FEE / e LESS / <br /> PRORATION I�I-�� kid GN 64 <br /> 1J11 y4A`. CeI2 �� "6 vim A/4f �./?"..C <br /> k <br /> PLUS <br /> PENALTY E� //_ <br /> OTHER A# 414'u Lct� yL� AJ Lit dF L ! �Q-� fi ( email Q. s2tw.Q <br /> OTHER (v <br /> Received by - Date Receipt No. - Permit No. - -- tssu riceD to Mailed- - Delivered"- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />