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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> AOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PLDMP&WELI <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY, ;c <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cohstruct and/or install the work herein described.This application is p <br /> made in compliance with San Joaquin County OrdiDjAnce No.186 nd the rules and regulations of the San 9 aquin Local Health District. <br /> Exact Site Address City/Town r9 <br /> Owner's'Name - i Phone1 <br /> Address - City-,z%_ � . <br /> Contractor's Name Va A& cl License#- Business Phone - <br /> Contractor's Address '1 r Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No rr�1 ll <br /> TYPE OF WORK (CHECK):-- -NEW WELL DEEPEN ❑ I-:- <br /> RECONDITION DESTRUCTION❑ <br /> WELL CHLORINATION E] WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ r PUMP REPAIR 11 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic TankC� -F-FJ _ Sewer Lin Pit Privy r--�- <br /> Sewage Disposal Field Cesspool/Seepage Pit _"`— Other. t <br /> Property Line Private Domestic Well 15� Public Domestic Well , <br /> INTENDED USE - TYPE OF WELL 2 !, <br /> ❑ INDUSTRIAL CABLE TOOL pia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC. ❑ DRIVEN Gauge of Casing r " <br /> 01 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 19r.�iyx/t <br /> PUMP INSTALLATION: Contractor j <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 /> n <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 />' k <br /> Contractor's hiring or sub-contracting signature certifies the following:"l certify that in the performance of the work forwhich this <br /> permit is issued, I shall mploy pe ons subject to workman's compensation laws of California." <br /> Jk*,iAC a ou Spec do uting and a final inspection. <br /> t "t' _ <br /> Signed X Title: 41 ic n! . . Date: <br /> jl� ' =. ? {praw Plot Plan on Reverse i e- <br /> e FOR DEPARTMENT USE ONLY <br /> PHASE I <br />_ Application Accepted By "-" �-- Date 7 a- + <br /> Additional Comments: <br /> 'Phase II Grout Inspection .. ,� , r ha III Final Inspection <br /> Et <br /> -Inspection By �� a; -�' Date' X � a'��.' Inspection.By � Da <br /> Q <br /> `- A" <br /> Fee Is Due: C1ANNUALLY ❑ PER UNIT 1:3PER SITE ElEACH. ElJanuary 1 &Received By January 31 ❑ July 1 &Receive $y July 31 <br /> ' REMIT <br /> 'BASE EXPLANATION BILLING . REMITTANCE AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> lair <br /> FEE <br /> LESS r n <br /> PRORATION <br /> PLUS �- <br /> PENALTY 't <br /> OTHER <br /> OTHER - - <br /> 89 SCI <br /> Received by 1 Date •Receipt No.� Permit-No—i y., l suance Date _ Mailed - Delivered,, - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 'STOCKTON,CA 95201 <br />