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- ` Applications Will Be Processed When Submitted Properly Completed. Be Su i� Sit YfSeApplication.o <br /> FOR OFFICE VaE: APPLICATION Ottt 16 1 4 <br /> (For Non-Transferable,Revocable,Suspendable) SL1L- FU 8010 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S �}_CN D <br /> Application is hereby madetotheSan Joaquin Local Health Districtfora permitto construct and/or instal;thewo erein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the of the San Joaquin Local Health District. <br /> Exact Site Address 'vO c�Z rty, ak <br /> c Pit) tMe /Town �� <br /> 634 W' Phone <br /> Owner's Name /CzV I <br /> Address S` �O f� �t��� 10C / n 1 . City <br /> l q License#� 11/1i Business Phone_ �— <br /> Contractor's Name - -,F <br /> Contractors Address GO / Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No p <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 2' PUMP REPAIR <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 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 /> 11DOMESTIC/PRIVATE 13DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout �+ <br /> ❑ DISPOSAL <br /> ❑ OTHER Other Information W <br /> ❑ GEOPHYSICAL Surface Seal Installed By: a <br /> PUMP INSTALLATION: Contractor SA ;fs ' y�+� <br /> Type of Pump— H.P. <br /> DUMP REPLACEMENT: 13State Work Done �'"� 0lG/Q <br /> PUMP REPAIR: C1 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 /> P <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, l shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a Grout Inspection prior to grouting and a final inspection. 7 <br /> Signed X N Title: _ Date: f 4_0 <br /> (Draw Plot Plan on Ree a Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I /7 �v <br /> Date <br /> Application Accepted By--Zrl�� <br /> Additional Comments: <br /> Ph a II Grout inspection Phase I11 Fi Inspection i <br /> ko <br /> Inspection By Date Inspection By�W Date <br /> f <br /> Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT <br /> 31 <br /> BASE EXPLANATION BSLLING REMITTANCE $ AMOUNT DUE= CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> Lf- C, �f5 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> F <br /> OTHER <br /> OTHER <br /> ' Received by Date Receipt No. Permit No. Issuance Date Mailed 1 Delivered <br /> 1401 E.HAZELTON AVE,,P.O.Box 2009 STOCI(TON;GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />