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LdJ <br /> >r` A Applications Will Be Processed When Submitted Properly Completed. r g h A II n + <br /> ,'FOR t1sE: APPLICATION C +d_� i <br /> (For Non-Transferable, Revocable, Suspendable) DEC 197P%MP&WELL 9 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> AN 'JGAQ! jfN LD^AL <br /> WATER QUALITY I S' <br /> i (COMPLETE IN TRIPLICATE) HEALTH DISTRE�a <br /> I Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkherein desc + ed.This application is <br /> made in compliance wit ! n � Count Or finance NO. 1EI62,and the rules and regulations of the San aquin Local Health District. <br /> k Exact Site Address Ad <br /> Gity/Tawn`�rI,p1► <br /> Owner's Name <br /> Phone <br /> City <br /> Address �, L —77-5-- <br /> C;ontractar's Name License# �2 Business Phone '-Contractor's AddressEmergency Phone <br /> Is Certificate of Workman's Compensatio Insurance on File With SJLHD? Yes No <br /> YPE Of WORK (CHECK): NEW WE DEEPEN 11RECONDITION 1:1DESTRUCTION❑ <br /> I WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> r REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 9 OCV-, Sewer Lines _ Pit Privy <br /> i <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> E 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 ra \ <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATIONty�('GRAVEL PACK Depth of Grout Seal - <br /> ❑ CATHODIC PROTECTION p54 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information 16 <br /> ' ❑ GEOPHYSICAL Surface Seal Installed By: �cdr ✓ 1 <br /> I 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 Approximate Depth r <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:"1 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 Ins e- ion prior to grouting and a final inspection.,. <br /> Signed X Title: Dater ,r <br /> ( �wpltPlan on Reverse Side) <br /> ORD ARTM T USE ONLY <br /> PHASE <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection P as III Final Inspection <br /> Inspectio y pate ��`- �� Inspection By Date <br /> 4/i i 1W t". .4 . ! fi ria . <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January & eed By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> l <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTEE AMOUNT <br /> FEE 4Y 3 <br /> LESSt <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> + OTHER <br /> I{ OTHER q <br /> Received by " Date Receipt No. Permit No- Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 45201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES <br />