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Applications Will Be Processed When Submitted Properly Completed. Be Sure T e Application. L_LJ ; <br /> Fo OFFICE USE: APPLICATION V 2 1979 <br /> (For Non-Transferable, Revocable, Suspendable) s <br /> ENVIRONMENTAL HEALTH PE MIT SAN J M DUCAL <br /> I / J PEEMIT <br /> ��. Tl�ICT � <br /> (COMPLETE IN TRIPLICAT, ! ! Sr ^ "' ATE �- } orAk.T -- <br /> Application is hereby madet he San Joaquin Local Health District fora it o constru and/or install the work herein described.This application is <br /> made in compliance with*144F <br /> quin County Ordinance No. 1862 and the rules and regulations of the Sa�Joaquin Local Health District. <br /> Exact Site Address kr �L i /Town 1-0A.-I <br /> 61 a <br /> Owner's Name _7D �1,A N >7.1� ✓)�. / ►ems/ Phone 8J� '.•3 /-.2 <br /> r,vc i� <br /> j Address A C City oegc <br /> C Contractor's Name s License# 7`'!47 Business Phone 9- -a2a0'Z <br /> k Contractor's Address Emergency Phone SA <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes/i!/�_ 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 x <br /> Sewage Disposal Feld 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 /> ❑ OMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC El DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _ <br /> ❑ DISPOSAL ❑ OTHER Other Information 6 <br /> f ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ' . .1p <br /> Type of Pump ._ 9 H.P <br /> PUMP REPLACEMENT: ❑ 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 L <br /> EE ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> f <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 /> t is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> r <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this € <br /> t permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspect' prior to grouting and a final inspectiM. <br /> Signed X Title: Dale: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR D ARTMENT SE ONLY <br /> PHASE <br /> r Application Accepted By Date �2fj- 7� <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 147Final In ection <br /> Inspection By Date Inspection By +°' ate <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ anuary 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BAS EXPLANATION BILLING RE NCE $ AMOUNT DUE CHECKED <br /> DATE A7£ REMITTED AMOUNT <br /> FEE <br /> 1 , <br /> LESS <br /> PRORATION <br /> PLUS i <br /> PENALTY <br /> y_ <br /> OTHER <br /> i OTHER <br /> r Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT 'RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - -- 1601-E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA <br />