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Applications Will Be Processed When Submitted ProperlyL:ompieleo. ae—,ulc IV'�� •'-ZgrtT7OU •• <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> SAN i r n <br /> UP� ELL <br /> r ENVIRONMENTAL HEALTH PERMIT HEALl ` `�'`' <br /> &'VI/ <br /> (COMPLETE IN TRIPLICATE) 76 � r S� WATER QUALITY <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 <br /> made in compliance with San,,Aoaquin County Ordinance No. 1862 and the rules and reg ations of the San Joaquin Local Health District. <br /> a.Exact Site Address <br /> l City/Town � +r <br /> ff- <br /> Owner's Name Phone <br /> Address - City <br /> Contractor's Name License#s3X2_ Business Phone--&-- <br /> Contractor's <br /> honeContractor's Address (!d Emergency Phone C> <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL ET"—'DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ / <br /> Priv <br /> DISTANCE TO NEAREST: Septic Tank �OG3 Sewer Lines `-� Pit Y <br /> Sewage Disposal Field 1 Cesspool/Seepage Pit -� Other -1 <br /> Property Line /0 Private Domestic Well r Public Domestic Well <br /> INTENDED USE TYPE OF WELL 1.1 <br /> !/ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation—t <br /> X DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC13DRIVEN Gauge of Casing <br /> 13IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> 13CATHODIC PROTECTION ,ROTARY Type of Grout <br /> 11DISPOSAL 11OTHER Other Information <br /> w �h <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: _ - 11 State Work Done <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 San 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 Grout Insp ction prior to grouting and a final inspection. <br /> Signed X Title: C�izf� � Dater <br /> raw Plot Plan on Reverse Side) <br /> FOR DEP RTMENT U ONLY <br /> PHASE I `( <br /> Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phas 11, 1 Inspection{ Phase III Final Inspection <br /> Inspection By Date I _ Inspection By Date <br /> Fee Is Due: ❑ ANN ALLY ❑ PER UNIT WIPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By"Iy 31 <br /> — REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE 41' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 1 <br /> V <br /> Received by Date Receipt No. Permit No. Is uance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMtTlSERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />