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r Applications Will Be Processed When Submitted Properly Completed. Be SureTosign TheApplication. <br /> FOS OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> _ 1 . WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY, t <br /> Application is hereby made tothe San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is I <br /> made in compliance /with San Joaquin Co`unEy Or finance No.1862 and the rules and regulations of the San Joaqui Local Health District. 7 <br /> Exact Site Address T�3� �++ y City/Town € <br /> r <br /> Owner's Name y' J Phone 3 1 &9 `{ <br /> Address * City— k <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's CompensationIns ranee on File With SJLHD? Yes No , <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ t <br /> REPLACEMENT❑ )' <br /> DISTANCE TO NEAREST: Septic Tank �� + Sewer Lines r Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line rivate Domestic Well ' Public Domestic Well <br /> INTENDED USE TYPE OF WELL l� <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation it <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing + <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> KIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal �' Q <br /> ❑ ROTARY Type of Grout ' <br /> 11 CATHODIC PROTECTION i <br /> Other Information <br /> 13 DISPOSAL OTHER <br /> 11 GEOPHYSICAL <br /> Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> i PUMP REPLACEMENT: 0 State Work Done <br /> PUMP REPAIR: r� State Work Done , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material 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 /> Contractor's hiring or sub-contracting signature certifies the following:"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 /> will Il for aut Inspection prior to grouting and a final inspection. <br /> Signed X CoS r Title: Date: <br /> 1 (Draw Plot Plan on Reverse Side) <br /> FO DEPA MENT U ONLY <br /> PHASE I Lt Date Q <br /> Application Accepted By <br /> ;1 <br /> 1 Additional Comments: I+ <br /> Phase 11 Grout Inspection se Ili Final Inspection ,r <br /> Inspection.By Date Inspection By Date. <br /> Fee is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEMIT By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> II FEE r' <br /> t LESS <br /> tt PRORATION <br /> PLUS <br /> I( PENALTY - <br /> [. OTHER <br /> III# OTHER ) <br /> 4 -Received by Date Receipt No. Permit No. Issuance Date Mai4ed De4ivered <br /> APPLICANT—RETURN ALL COPIES TO:.'k V ENVIRONMENTAL HEALTH PERMITlSERYICES', 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 45201 <br /> - - - - — "r <br />