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Applications Will Be Processed When Submitted Properly Completed. B e��itellp�lic n <br /> FOR•OFMCE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspend :e992 <br /> i 4v G '"W <br /> E!! a k <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 6 �A� JOAMN LOCAL <br /> Application is hereby made to the San Joaquin Local Health Districtforapermit toconstruct and/or instal�e er �.td� �.Thisapplication-is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> Exact Site Address 2 614/� City/TownetAyloek.t 9S72-0 j <br /> Owner's Name Phone <br /> Address n � �" ' City <br /> Contractor's Name -�3 ' `= License# Business Phone <br /> Contractor's Address G ,Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance 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(- <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> = <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation - <br /> 50 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL - ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL � ��- _ Surface Seal Installed By: - <br /> �l <br /> PUMP INSTALLATION: Contractor 5 � <br /> `5 Type of Pump P. <br /> PUMP REPLACEMENT:: ~t IN State Work Done <br /> rP <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 Sari 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 /> 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 Ins p n prior to grouting and a final inspect' <br /> Signed X � / -C-4 901!4� Title: Date: <br /> } (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By �' `� Date� a <br /> Additional Comments: <br /> Phase 11 Grout Inspection Phase III Final Inspection r� <br /> Inspection By Date Inspection By Date d�/043 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATkONy DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -Receivecf by Date -Receipt No. - Permit No. Issuance Date Mailed Delivered - -- - - <br /> i <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> J <br />