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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> -JR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) r 77 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance wi J In Cou rdinance No 62 a t rules and regulations of the San Jo4quyn Local egdh District. <br /> Exact Site Address City/Town ` <br /> I <br /> Owner's Name 7�1�G� _ Phone . <br /> Address �_ City <br /> Contractor's Name S S, Lice Gv Business Phone,— - -- -- <br /> Contractor's Address 3_ l Emergency Phone <br /> Is Certificate of Workman's Compensation s rance on File With SJLHD? Yes � No <br /> TYPE OF WORK (Cl NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCT{ON❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank L " Sewer Linesrte__ _ 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 f� 1 <br /> El INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavatio/i!1 l/I <br /> iDOMESTIC/PRIVATE RILLED Dia. of Well Casing Y'G �t �1 <br /> DOMESTIC/PUBLIC DRIVEN Gauge of Casing C <br /> IRRIGATION ❑ RAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION kR❑ OTARY Type e of Grout <br /> ❑ <br /> DISPOSAL OTHER _ Other Information <br /> ❑ GEOPHYSICAL (Surface Seal I talled By: <br /> PUMP INSTALLATION: ContractorAX t�f �� _ <br /> Type of Pum �L iii-15r H - - - - <br /> PUMP REPLACEMENT: ❑ State Work Done- <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Wel! 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 /> 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 forwhichthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I cal r rou spection prior to grouting and a final inspection. ,d / <br /> Signed_ - - - - isle: !��`/�eg /��' Date: <br /> � 6 . <br /> _ <br /> {Draw Plot Plan on Ree se Side} <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted ByA"O_� - _. Date <br /> Additional Comments: <br /> ,pPhaseII Grout nspection Phase III Final Inspection <br /> Inspection By Date 7_1:�" Al' _ Inspection By _ Date <br /> - / <br /> Fee IS Due: 1:1 ANNUALLY E] PER UNIT 1:1 PER SITE ❑ EACH ❑ January 1 &Received By January 31 E:1 July 1 &Received By July 31 <br /> - .. .. —. - - <br /> BASE EXPLANATION BILLING REMITTANCE REMIT <br /> AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE - — — <br /> LESS - <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER -- � - -. — - <br /> � <br /> Received by Date Receipt No. Permit No. Issuktce D to ' M1l�ailed Delivered <br /> APPLICANT—III ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Baa 2409 STOCKTON,CA 95201 <br />