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.�+-v-,+ •".' _�.Appcatlons-will^!TeYsacesmcu 7r- <br /> FO R tJFFfCE USE: APPLICATION <br /> (For-Non-Transferable,'Revocable;,•Suspendable) <br /> ENVIRONMENTAL HEALTH-PERMIT', <br /> WATER QUALITY r <br /> (COMPLETE IN TRIPLICATE) <br /> P.aplication is hereby made to the San Joaquin Local Health Dis rict or permit to construct instal the herein described."This application 40 <br /> made in compliance w San a in�punty-Ord ance. .0 3862 and the rules an g tions of the:5an J nH� h� Dict• -_- <br /> Exact Site Address <br /> l�� City/Town. <br /> Phone <br /> Owner's Name L' , <br /> Address <br /> Z _City <br /> ---. � <br /> Contractor's Nam Jr-r_ License - Business Phone <br /> Emergency Phone <br /> Contractor's Address i <br /> is Certificate of Workman's:Compensation Insurance on:Fife With SRECO Yes NoNDITION❑ DESTRUCTION© <br /> TYPE OF.WORK (CHECK): ',`N EW WELL El DEEPEN <br /> ❑ RECO , <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ -. PUMP INSTALLATION PUMP REPAIR , <br /> ,REPLACEMENT❑ f <br /> Sewer.•Lanes Pit Privy <br /> DISTANCE TO.NEAREST: Septic Tank Other- <br /> Sewage Disposal Field :•-� � Cesspool/Seepage Pit.,. � - <br /> _ - - , <br /> ax ; a`Property Line Private)OMeStiC Well _'Public Domestic-Weil. <br /> INTENDED USE _ ,.TYPE OF:WELL <br /> Dia. of Well Excavation - <br /> I ` TRIAL �.,., ❑:fbABLE.TOOL - - <br /> DOMES <br /> TtC/PRIVATE^ 13 DRILLED Dia. of WeN.Casing — <br /> ❑ pOMESTIClP.UBLIC <br /> El DRIVEN Gauge of Casing <br /> C3GRAVEL PACK Depth of Grout Seal.. <br /> f ❑ IRRIGATION Type of Grout <br /> ❑ CATHODIC PROTECTION Elrou <br /> ROTARY- j - <br />' Other Information <br /> ..3 DISPOSAL <br /> .©-OTHER � "' -T� <br /> ❑ GEOPHYSICAL Surfaeal installed y: <br /> Contract 7 4 �j N <br /> PUMP INSTALLATION: :: :':' H.P. <br /> Type of Pump <br /> ..PUMP REPLACEMENT::-. ❑ State Work Done <br /> 4 .PUMP REPAIR: ❑ State Work Done - -� <br /> Well Diameter ` Approximate Depth <br /> DESTRUCTION OF WELL: <br /> 'Describe Material and Procedure <br /> 4 I hereby certify that l have prepared thisapplicatio�and that the work-will be done in.accordance with San Joaquin County' a <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> wfiome aviner-or licensed agent's signature certifies the fottowing:''I certify that in the performance:of.thework for which this permit <br /> -is.issued; I shall not employ any person in such:manner,aslo>become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub=wntracting signature certifies theiollowing.. ertify that,in•the:performance°of the work for which this <br /> . pe itis issued, I.shall employers bject to workmanscampensation,laws of Gallfornia. 4 <br /> call for a r tit Inspe 3n:,to / outing and a final inspe on <br /> i� Title: Date- a <br /> Signed );k <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPART ENT USE ONLY <br /> =PHASE 1 -0 Date <br /> App Iicatlort Accepted'By <br /> F <br /> ... Additional.Comment s: <br /> � Ph se III Final Inspe tion <br /> Ptlase II Grout Inspection <br /> �. Inspection By <br /> rate Inspection_By ate• <br /> - ❑ PER Y_IMT ElPER SITE El EACH ❑ January 1 &Received By January 31 13 July 1'&.Received By July 31 <br /> Fee l5 Dile' ❑ 'ANNUAL•LY <br /> REMIT <br /> .BILLING REMITTANCE $ AMOUNT DUE ,.:•`CHEG4<EO, <br /> BASE EXPLANATION TE DATE REMMTED AMOUNT <br /> ' o <br /> de) <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> r PENALTY <br /> OTHER >" <br /> t OTHER - - <br /> r�. <br /> - Permit No. -Issuance pale Mailed Deliveredy <br /> Received by Date Receipt No. ,�_„+- —�_._ l <br /> 1601 t:.HAZELTON AYE.�P:O-Bo�e_2C09-�_STOCKY N,CA 95201 <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES - `, F. ,r <br />