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Applications Will Be Processed When Submitted Properly Completed B " 1"pphe q-plat.a <br /> FOR t�Flc USE: r_ APPLICATION <br /> (For Non-Transferable, Revocable, Suspenda l9�,�qi <br /> t5 �Y 2 1ytSIMP ELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madetotheSanJoaquin Local Health Districtforapermit toconstruct and/or ins t ftheNrorktrer�__Iri les8ribec?.�-This application is <br /> - a.l ­7 <br /> made in compliance with San Joth c�aqui CoCou Ordinan a No. 1862 arules and regulations of the' rl qw Ldcaf`W� Ath District. <br /> Exact Site Address / / k, City/Town F <br /> Owner's Name ` i "°l Phone U r7 <br /> Address City a <br /> Contractor's Name License#/t�.�.31� Business Phone <br /> Contractor's Address 3 <br /> r Emergency Phone �4 <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❑ <br /> REPLACEMENT <br /> DISTANCE AREST: 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 /> ❑/INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <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 , (� S rface Seal Installed By: <br /> PUMP INSTALLATION: Contractor �1 d-�'-�� �. -� <br /> Type of Pump- _ <br /> ump _�1 1 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 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 /> an <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that In the perform ce of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I wi II f r a Grout I pection prior to routing and a final inspection. <br /> Signed X Title: � Date: <br /> (Draw Plot Plan on Reverse-fide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Applicationl <br /> Accepted By ��"' Date <br /> Additional Comments: <br /> Phal II Grout Inspection P"se III Final Inspection �� I <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive_d B_y___ Ja y ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE ��� O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. dssuance qwe I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONAVE.,P.O.Boz 2009 . STOCKTON,CA 95201 <br />