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,r A .,... <br /> Applications Will Be Processed When Submitted Properly Complete d.BeSure <br /> APPLICATION =� <br /> FOR OFF,IGE USE: <br /> (For Non-Transferable,Revocable;Suspendable) � PUiVIP"&WELL <br /> ENVIRONMENTAL HEALTH PERMIT � �Ly <br /> Y WATER QUALITY :r11 rel I <br /> (COMPLETE IN TRIPLICATE) <br /> .This <br /> R° <br /> Application is hereby made to the San Joaquin Lo <br /> oadl HanacehNo518fi2 andtrict f Or 8 phe ides and regulations oftthe San Joaquinthe work- )Local Healdth District.lication Is <br /> made in compliance with San Jo 'ryCounty O <br /> � � � - City/Town � I <br /> Exact Site Address <br /> Phone <br /> Owner's NameTIN :.. City Business Phone <br /> Address r- <br /> Contractor's Name w �- Emergency Phone <br /> Contractor's Address _ No <br /> Is Certificate of Workma 's Compensation Insurance on File With SJLHO? Yes STRUGTI NO - <br /> NEW <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION <br /> ❑ WELL ABANDONMENT � OTHER ❑ PUMP INSTALLATIOPd� PUMP REPAIR❑ <br /> WELL CHLORINATIONr <br /> IN <br /> REPLACEMENT❑ * --- <br /> : ._ Sewer Lines-__`c R_-"""`"c- ?it-Privy i <br /> DISTANCE TO NEAREST:'" Septic Tank CesspooVSeepag�Pit—.- Other - <br /> Sewage Disposal Field Public Domestic Wel I�""�"-� - <br /> Property Line Private Domestic Weil �--- <br /> TYPE OF WELL <br /> INTENDED USE <br /> ❑CABLE TOOL Dia.-Of'-Well-Excavation <br /> 13 INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE Gauge of Casing ' <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11 GRAVEL PACK Depth of Grout Seal' <br /> [3 IRRIGATION - Type of Grout <br /> ❑ CATHODIC PROTECTION ROTARY '_` " _ I <br /> ❑'OTHER -77-1 Other'InfoirriationT <br /> ❑ DISPOSAL g 'ice Seal installed ay:' <br /> ❑ GEOPHYSICAL t � <br /> 4 PUMP INSTALLATION: Contractor - H P <br /> Type of Pump i4} <br /> I PUMP REPLACEMENT: ❑•State Work-Done , v - <br /> 13 State Work Done <br /> PUMP REPAIR: 1� Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure_. <br /> hereb certify that I have prepared this application and that the be done in accordance with San Joaquin County <br /> the work will <br /> I Y <br /> 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 /> 'comet <br /> aws of Caifrnia." <br /> is issued, I shall not employ any person ittfy thawort in the perforomance oflhl <br /> in such manner as ework forwlhioch this <br /> „l cer <br /> Contractor's hiring subcontracting signature certifies the following: <br /> permit i§ issued, l shall employ persons subject to workman's compensation Paws of California." <br /> I call for a G i1 rior to grouting and a final inspection. <br /> Title: ` Date: <br /> Signed X" (Draw Plot Plan on Reverse Side) <br /> + FOR EPARTMENT USE ONLY : <br /> i � <br /> PHASE 1 f r Date <br /> Application Accepted By `s <br /> Additional Comments; -{ pha (nal inspection <br /> 'Phase ll Grout Inspection '�,.�; Gr ... pate <br /> inspection By <br /> Inspection sy Date <br /> ❑,January_t &Received By January 3b July 1 S Received By July <br /> 31 <br /> REMIT <br /> EACH S <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑"PER'SITy $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE, - - AMOUNT <br /> EXPLANATION ' -"- <br /> BASE EXPLANDATE REMITTED <br /> � + � `DATE - <br /> FEE T <br /> LESS a s <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER / <br /> * S� <br /> A Issuance ate-. Mailed Delivered <br /> Date 01 <br /> '. <br /> Receipt No. Permit No. <br /> Received by 1661 E.HAZELTON AVE.,P.O.Box 2008 STOCKTON,CA 852 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />