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—,:rr� <br /> Applications Will Be Processed When Submitted Properly Co d1Me sl o�i T1 AS—_--tion. <br /> FON OFFICE USE: APPLICATIO <br /> (For Non-Transferable,Revocable, I andable) pU E <br /> 4p <br /> ' ! , ENVIRONMENTAL HEALTH PER�T1`'` � � <br /> `I � = <br /> r, <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY l r, F , <br /> SAN OPO i 1IN A <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct a' hFFia} 6scribed.This application Is <br /> made in compliance with San Joa in County Ordinance N .1862 and the rules and regulation--s ofe�a guTn"L al ealth District. <br /> Exact Site Address, Q-. w City/Town40 <br /> Owner's Name r Phone �Z(v "' 13 <br /> Address 4 &,k City <br /> Contractor's Name JE3 License#I C.Z ' 3 Business Phone *'Z �6 •� tf <br /> Contractor's Address Emergency Phone OQ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR /6 <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 /> k INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 11 DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal - <br /> 11 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor °�, A <br /> Type of PumpH.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done p <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 /> Homeowner 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 =fot ection Prior to grouting and a-final inspection. {{ <br /> Signed X tie: Date��d^92;,-� <br /> (Draw Plot Plan on Rever Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By Dates <br /> Additional Comments: <br /> Phas 11 Grout Inspection PhasYe Ill Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 0 July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE ' E �Z7 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is, Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />