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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application_FOR OFFICE USE: APPLICATION <br /> -T x" Cp ctrh /0+4Wf (For Non-Transferable, Revocable, Suspendable) p(JMR&WELL ..� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) �5�� S f7� � WATER QUALITY c� —� <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is t <br /> made in compliance with San Joaquin County rOr. inj�ce o. 18 2 d he rules an regulations of the San Joaquin Local�ilealth District. <br /> AA do A:— <br /> Owner's <br /> /fid ff 4 � d dY .1 A�� City/Town <br /> Exact Site Address_r_ D.L] - <br /> j-o yA S Phone <br /> Owner's Name _ <br /> Address <br /> Contractor's Name License# !L'/,�2 r�City <br /> —7hi_ Business Phone 6Y 7-9 <br /> Contractor's Address k + Emergency Phone ; <br /> Is Certificate of Workman's Compensation Insurance on File With SJ . D? Yes DESTRUCTION <br /> NO ] <br /> _TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN 11 RECONDITIONLa DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field � Cesspool/Seepage Pit Other <br /> 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 <br /> ❑•DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> I� IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL n urf eal Installed <br /> PUMP INST4. <br /> ALLATION: Contractor tel" <br /> r t <br /> Ad <br /> Type of Pumpu'f H.P. p <br /> PUMP REPLACEMENT: ❑ State Work Done �{ <br /> PUMP REPAIR: State Work Done O V <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 I <br /> 5 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> I <br /> Homeowner or licensed agent's signature certifies the following:°I certify that in the performance of the work for which this permit G <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." a <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ person t to workman's compensation laws of California." <br /> 1#11 call for a Grout Inspe fiop to gr ng and final inspection. 1 <br /> Signed ill e: <br /> .� µ Date: L 1� <br /> {Draw Plot Ian on Reverse Side) <br /> FOR DEPAR MENT USE ONLY <br /> PHASEI �G c <br /> Application Accepted By Date <br /> Additional Comments: <br /> i Phase II Grout Inspection Phas#'Ijkjqnal Inspection <br /> Inspection By Date Inspection By Date 12 <br /> 4r <br /> I. Fee Is Due: 13 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Suly 1 &Received By Jury 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> r PRORATION <br /> t PLUS 4 <br /> PENALTY <br /> OTHER <br /> OTHER <br /> --y <br /> Received by Date Receipt No. Permit No. Issuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 f <br /> r <br />