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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> tt APPLICATION <br /> t (For Non-Transferable, Revocable,Suspendable) &WELL + <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ��JJ�� <br /> COMPLETE IN TRIPLICATEWATER QUALITY <br /> Application is hereby made tothe San Joaquin Local Health District for apermit toconstruct orinsfatiTPSeworkherein des ed.This application is <br /> made in compliance wit San Joaquin County Ordinance No 186 a the r les an gulations of the San Joaquin o al Health District. <br /> Exact Site Address City/Town � 7Ofcecyl <br /> Owner's Name r O PhoneJ!/ <br /> Address City__L <br /> Contractor's Name License Business Phone ,��-1 �/ e) <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_X — No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION IiDESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 1 J <br /> DISTANCE TO NEAREST: Septic Tank t Sewer Lines - Pit Privy <br /> Sewage Disposal Field �//0 C} —E Cesspcoc,I/seepage Pit Other <br /> Property Line Private Domestic Well�, [ :t Public Domestic Well <br /> INTENDED USE TYPE OF WELL q C� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 0< # <br /> '11-DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: =(gel I&C <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 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 <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 certifythat 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 perspAs subject to workman's compensation laws of California:" <br /> I!wMf Gr I In ctio r to grouting and a final inspection. t <br /> Signed X Title: Date: y j <br /> (Draw Plot Plan on Reverse e) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I k\._ k� <br /> Application Accepted By I/�- vlfvrw-. Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By <br /> 4R s P/ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received B ry 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 4N Q. 1' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t3 I `� <br /> Received by Date Receipt No. Permit No. isquance to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />