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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) VvL1 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Cou ty Or mance No. 1862 and the rules and regulations of the San rin LpcI Health District. <br /> Exact Site Address 71/f o /iugK City/Town/� �' Cly A <br /> Owner's Name ��`� �\ (J� i Phone_ `1 7 r � � <br /> Address `f �it! City CCIc <br /> Contractor's Name � � w _ License#e��s",S"�•/3 BusinpssPhone <br /> Contractor's Address 00 +'-�Q,w.i« ` Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes K _ No 4J1 <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTIONS y <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <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 X Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation_ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Z_ � <br /> ❑ 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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done _ (f1 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: \f Well Diameter_ �-� Approximate Dep h <br /> Describe Materi and Pro e ure <br /> I hereby certify that I have prepared this application nd 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 performanceof the work forwhich 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 /> J <br /> ll c I for a Grout spection prior to grouting and a final inspection. <br /> Signed X vu- Title: S:�W�`"- 0I"' _ Date: ! Y <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �} <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection se�III Fi tion <br /> Inspection By-- <br /> at Date _ Inspection <br /> B. <br /> e & Z <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT PER SITE EACH ❑ Janu 1 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTAN� $ AMOUNT DUE CHECKED <br /> _ DATE DATE REMITTED _ f _ AMOUNT <br /> FEE 1 D b�c <br /> LESS <br /> PRORATION <br /> PLUS .. +. _ .. <br /> PENALTY <br /> OTHER --- <br /> OTHER <br /> Received by [Tate Receipt No, Permit No- Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA2:ELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 <br />