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Applications 1NIII Be Processed When Submitted Properly Completed. Be SureTo sign ineapplication. ` <br /> I <br /> APPLICATION <br /> RLUSE,FOi (For Non-Transferable, Revocable,Suspendable) <br /> FUMF&WALL <br /> 4. <br /> ell, <br /> I i ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY � <br /> (COMPLETE IN TRIPLICATE) i i z� <br /> Application is hereby made to the San!Joaquin Local Health District fora permit to construct and/or install the work herein described.This applicatisn is <br /> made in compliance with/San Joaqui'i C unty OrdinanFe No. and the rules and regulations of the SanJiquin Local( realth District. <br /> I r / III I !!r City/Town <br /> Exact Site Address /� I�I f } <br /> �.-�� Y41�fJ n� Phone f <br /> Owner's Name qI City <br /> address <br /> ' License#i � Business Phone <br /> Contractors Name , ! <br /> Contractor's Address 01 �1 I Emergency Phone i <br /> ql: <br /> Is Certificate of Workman's Compens1.ation Insurance on File With SJLHD? Yes No <br /> TYF.F OF WORK (CHECK): NEW WELL} DEEPEN ❑ RECONDITION❑ DESTRUCTION[]❑ <br /> AIR❑ <br /> WELL gHLORI NATION 13WELL ABANDONMENT 11OTHER ❑ PUMP INSTALLATION ❑ PUMP REP <br /> REPLAC:MENT❑ II: f <br /> ' <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ��� Pit Privy f <br /> Sewage Disposal Field Ci),_ Other <br /> Cesspool/Seepage Pit ` <br /> Property Line- Private Domestic Well YO t Public Domestic Well <br /> F WELL <br /> INTENDED USE TYPE O <br /> C3 CABLE TOOL Dia. of Well Excavation <br /> 11 INDUSTRIAL � <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 13 DOMESTIC/PUBLIC i I 11 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL I ❑ OTHER Other Information ; <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> 660hld.1 <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: I I ❑ state Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: f i <br /> Well'Diameter Approximate Depth I <br /> Describe Material and Procedure <br /> I hereby certify that I hlave 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 /> r Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework 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 /> 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/per ons subject to_workman's compensation laws of California." �� (Z a 1-7 <br /> I will all fora tit pec o�i r'iori10 grouting jand a final inspection. <br /> .If r Akv <br /> Title: + Date: <br /> Signed X .. <br /> [Draw: ide)Plot Plan an Rever� _ h <br /> FOR DEPARTMENT USE ONLY y J rrvr. V <br /> # 'PHASE I 7��Date _ 79 ,,kT44 giiv <br /> Application Accepted By 'fI G e n <br /> Additional Comments: OF <br /> Phar II Grout Inspection Phas 111 Final Inspection <br /> i ate P Innspe tion By Date <br /> Inspection By �yy'�yR`4 <br /> V ❑ Januar 1 &Received By January 31 ❑ Ju y 1 &Received By J y 31 <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH y r REMIT <br /> II iII. BILLING REMITTANCE $ AMOUNT DU�Z CHECKED <br /> BASET EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE F . �', GIP _ <br /> LESS S=S IIT. <br /> PRORATION' <br /> r ` <br /> PLUS <br /> t PENALTY <br /> 4• �'•� <br /> � OTHER <br /> X�I s L <br /> OTHER <br /> Date Receipt No. Permit No. I suance ate Mailed Delivered <br /> Received by =IF <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITT/SE ES 1601 E.HA2ELTON AVE.,AYBP.O.Box 2009 STOCKTON;CA 201 <br />