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AppucaIonswm uevrocessea wnen 5uomn1e0ProperlyGomplete0. Be 5T e P11? <br /> l ti r k <br /> FOR OF'FIC it APPLICATION <br /> (For Non-Transferable Revocable,Suspen <br /> ENVIRONMENTAL HEALTH PE <br /> MAR O 198fU &WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Cl <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or irthsidu��yy-���`e`�ll$(el.This application is <br /> made in compliance with Sa Joa�gruin County Ordinance No. 1862 and the rules and regulations of� aT! gtiAh 1alth District. <br /> Exact Site Address ��.3 W Q :I,� lu• City/Town <br /> Owner's Name Phone .S - 7?7 7 S)e <br /> Address a S City <br /> Contractor's Name License Business Phone <br /> Contractor's Address !/' k2 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❑ DESTRUCTION❑ �'Lf} <br /> WELL CHLORINATION ❑ WELL ABANDONMEN7Vq, OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 4 <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 /> 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 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter— Law ¢ :� ?-? Approximate Depth <br /> Describe Material and Procedure , Q _50' P �- �„Lzic. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County W <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. W <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 not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the fallowing:"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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X _ Title: 3?!.t Date: .✓w r f <br /> (Draw Plot Plan on Reverse Side. <br /> F , DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection els al inspection 'f <br /> Inspection By Date Inspection By Date <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 0 / <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Z51 -3 //7121 <br /> Received by Date Receipt No- Permit No. I uance Date Mailed Delive+ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1501 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />