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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. Kr <br /> LT :7 <br /> APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> P(lAsP <br /> 43EY ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquiq Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa in County Ordi ante No. 1862 and the rules and regulations of the San Jo quip Loc ealth District. <br /> Exact Site Address_ y „ <br /> — — Cit /Town <br /> Owner's Name . + <br /> Address ` — Phone — <br /> Contractor's Name _ City <br /> Licee sinsPhohe <br /> Contractor's Address � Bu7� 6— <br /> e �f Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? — <br /> DESTRUCTIONb <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION <br /> Yes_` y No <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER 0 ITI PUMP INSTALLATION 'PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank — <br /> —. Sewer Lines _ — Pit Privy <br /> Sewage Disposal Field — _ Cesspool/Seepage Pit — <br /> _ OtherPro <br /> Property Line_ Private Domestic <br /> Well_ Public Domestic Well <br /> INTENDED USE TYPE OF WELL — <br /> �❑ I USTRIAL ❑ CABLE TOOL <br /> 11r DOMESTIC/PRIVATE Dia. of Well Excavation <br /> ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> ❑ IRRIGATION Gauge of Casing <br /> 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION <br /> 11 DISPOSAL ROTARY Type of Grout _ <br /> ❑ OTHER Other Information <br /> El GEOPHYSICAL — — — <br /> PUMP INSTALLATION: Gontractor Surface Seal Installed By: <br /> — r <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done — — <br /> PUMP REPAIR: El State Work Done------------- <br /> DESTRUCTION OF WELL: Well Diameter— <br /> Describe Material and Procedure — Approximate Depth — <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-cont 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 /> ca or a Grou Inspection prior routing and aMnal inspection. <br /> Signe <br /> Title: .... -. .a , -.®. _ Date: <br /> (Draw Plot Plan on R erse Side) <br /> FOR DEPARTMENT USE ONLY .. <br /> PHASEI Application Accepted By �� ��� <br /> Additional Comments: Date . <br /> rout Inspection —�— <br /> Inspection By— Ph e III F4naf Inspection <br /> Date — — Inspection By `f <br /> i c —_ Date — — <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT � <br /> _ ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 <br /> I 1— — — — — —-- — .— July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE r��r — — — -- _ AMOUNT <br /> LESS //y <br /> PRORATION <br /> PLUS — — — — — — — <br /> PENALTY —�— — <br /> OTHER — — — — — — — — -- — — — <br /> OTHER <br /> Received by Date Receipt No. � ` --� _ _ <br /> APPLICANT—gETIJRN ALL COPtEs TO: ENVIRONM Permit No. Is uancce to Mailed — <br /> ENTAL HEALTH PERMIT/SERVICES Delivered <br /> 1601 E.HAZELTON AVE.,P.O.BOM 2009 STOCKTON,CA 95201 � <br />