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Applications Will Be Processed When Submitted Properly Comple ei Bn S'Uri'r,6 SI§n theBELL <br /> n. <br /> FOR OFFICE USE: APPLICATION „�� y 1f <br /> (For Nan-Transferable, Revocable Silieiidable) Jill <br /> ENVIRONMENTAL HEALTH PERMIUG <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY. F..t -�;? Es, Gia . <br /> Application is hereby made to the San Joaquin Local Health District for a,permlttoconstructand*Iiaa vpvuimm"I'Tescribed.This application is <br /> made in compliance with San Joaquin-County Ordinance No. 1662 and the .rules and regulations of the San J aquin Local Health District. <br /> City/Town J. <br /> Exact Site Address S ' <br /> Ph one -►” ''v '► _ <br /> Owner's Name <br /> Address /! <br /> �z '"''r°�' ) ifi License# 2 Business-Phone' <br /> Contractor's Name vcs <br /> Contractor's Address <br /> p- a. } Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> E TYPE OF WORK {CHECK): NEW 1IVELL❑'—DiEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL.CHLORINATION 13 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ �) ; <br /> REPLACEMENT❑ lUi <br /> � <br /> DISTANCE TO.NEAREST: Septic Tank' Sewer Lines Pit Privy ► <br /> Sewage Disposal Field Cesspool/Seepage Pit 1 Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USETYPE OF_WELL, <br /> � <br /> Er <br /> ❑- USTRIAL CTOOL'TOODia. of Well Excavation <br /> l� DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 13 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION I] ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER-, R Other Information <br /> ❑ GEOPHYSICAL - T Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor - <br /> I Ty of Pump '" H.P. <br /> I <br /> Typo-of <br /> I PUMP REPLACEMENT: M State Work Done tiv I r. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> i <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance'of thework forwhich this permit s <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 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X a- Title: Date* <br /> (Draw Plot Plan on Reverse de) <br /> FOR DEPARTMENT USE ONLY Q <br /> PHASE I — <br /> Application Accepted By - Date <br /> Additional Comments! T . <br /> Phase 11 Grout Inspection vM j - a IU Fi Inspection <br /> inspection By <br /> Date - - Inspection By Date2I <br /> Fee IS DUE: 13 ANNUALLY ❑'PER UN17 ' ❑ PER SITE' El EACH i ..0ary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION B1LLIlNG A REMITTANCE- - - $ � - AMOUNT DUE r CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> I FEE 5 do- <br /> LESS LESS <br /> PRORATION <br /> PLUS f <br /> PENALTY <br /> OTHER <br /> OTHER <br /> r > , <br /> +-Received by- Date -- Receipt No. <br /> -- Permit No - te Mailed Delivered', <br /> . ^- - ssuanc Da - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P:O.Box 21104 STOCKTON,CA 95201 <br />