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Applications Will Be Processed When Submitted Properly Completed. Be Sure To top2Pt&.V � UUAPRI„(CATION u <br /> A�, <br /> (For Non-Transferable, Revocable,Suspendable) {�1 <br /> AP R P�f�P���VELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) X337" " z� TEA QUALITY . �_?—w—,,$AN JOAQUIN LOCAL <br /> . S -G�.I�e.S�.,r,4ri:1-� �r� p �+ <br /> Application is hereby madeto the San Joaquin Local Health District for a permit to construct and/or install the work HEALTJ�, !,$ UQJplicationis <br /> made in compliance with San Joaquin/Co ty Ordinance No. 1862 and the rules and regulations of the San�Joagyip oval lth Di tris <br /> - Exact Site Address City/Town <br /> Owners Name Phone <br /> Address 1019e ZrV 0—ev7 City_ <br /> Contractor's Name icense#D� '?f, G Business Phone /�._ ✓`��"-9� <br /> Contractor's Address jrElpergency Phone <br /> Is Certificate of Workman's CompensationI urance on File Wi ? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL L DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORIN AT N 0 WELL ABANDONMENT ❑, OT R ❑ PUMP INSTALLATION El PUMP REPAIR El <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank S er Li Pit Privy <br /> Sewage Disposal Fie Cesspool/Seepage Pit Other <br /> Property Line Priv a Domestic Well Public Domestic Well , <br /> INTENDED USE TYPE O WELL �„ <br /> 13 INDUSTRIAL 11 CABLE TOOL Dia. of Well Excavation F <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing s <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal a� <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 Dane IJA <br /> PUMP REPAIR: ❑ 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:1 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California.'; <br /> i <br /> I will call a Grrt Ins c o prior togroutinga a final inspection. R <br /> Signed X L[ G� .ti `� 1 Title: V T Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Vu t <br /> Application Accepted By Date <br /> Additional Comments: w <br /> Phase II Grout Inspection Phase Ili Final Inspection I <br /> t <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE- ❑ EACH ❑ January 1 &Received By January 31 ❑ Juty 1 &Receivep,py July 31 <br /> BIL N EMITTAN $ 5MIT <br /> BASE - EXPLANATION D DAT MITTED AMOUNT DUE CKED <br /> AMOUNT 4 <br /> FEE `S <br /> LESS l 1 <br /> PRORATION 2 <br /> PLUS a <br /> PENALTY <br /> OTHER �* I <br /> OTHER <br /> Received by.. ate Receipt No-,_ Permit Nolssuanc&WTe - Mailed f5eliyered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES-- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />