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ApplicationswinDerrocessea�wnen,.7UonvinVUrMplIFFITwr,tnpisrpa.oeaure Iv01VII IneAPPncaavn. <br /> FOR OFFICE USE: -.APPLICATION <br /> (For Non Transferable,Revocable,Suspendable) <br /> .ENVIRONMENTAL 11110ALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) l Z ' /a Va I C,,;o� WATER QUA►Il <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construt end/or install the work herein described.This applicati s <br /> made in compliance with San Jgpuin County Ordinanceo. 1 62 anqLthhe rule bind ' <br /> /regula oils of the San Joaquin Local Health°District. <br /> Exact Site Address L&C 77FF� _",g &djr&o4 71Z -- ity/Town + oc/Uav -{y <br /> Owner's Name <br /> Address <br /> Contractor's Name License k business Phone ^ <br /> ,.Contractor's Address Emergency Phone " <br /> Is Certificate of Workman's Compensation-insurance on File With'SJLHD? Yes _ No <br /> TYPE OF WORK (CHECK): NEW WELL ',,DEEPEN-0 RECONDITION 13 DESTRUCTION❑ <br /> 'WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER CI PUMP WSTALLATION'❑ PUMP REPAIR❑ .� <br /> REPLACEMENT❑ r / <br /> DISTANCE TO NEAREST: Septic Tank Sty t Sewer Lines „ © f _ Pit Privy <br /> Sewage Disposal Field /400(#- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Welt,A57e_-f_ Pubiit -Qornestic Well -�- - - <br /> INTENDEt3 USE TYPE OF WELL t/ <br /> ❑ INDUSTRIAL ❑ CABLE TOOL. Dia. of Well Excavation J <br /> DOMESTIC/PRIVATE ❑ DRILLED Dial.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C_ — <br /> ❑ IRRIGATION GRAVEL'PACK Depth of Grout Seal ` <br /> ❑ CATHODIC PROTECTION ROTARY : ._ type of Groutc <br /> ❑ DISPOSAL ❑ OTHER Other Inforniation 466 az 061 74 <br /> ❑ GEOPHYSICAL ` urface Seal Installed By: t <br /> PUMP INSTALLATION Contractor <br /> Type of Pump _ H.P. <br /> PUMP REPLACEMENT: s,_,; ❑ 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 this lwoek will be done in accordance.with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the San Joagltin focal Health District. V. - <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 ocsub-contracting signature certif esthe following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persops subject to workman's-compensation laws of CaNtornia." <br /> -4-will call for a Gr tit In#,ectioi n rto grouting and,atinal inspection. <br /> Signed )C Title: nl Date: cS <br /> (Draw Plot Plan on Reverse Silk) <br /> FOR DEPARTN}ENT USE ONLY <br /> PHASE I �/►�y <br /> Application Accepted B Xv c1 Dat <br /> Additional Comments: <br /> Phase It Grout4rispection P ase III Final Inspection <br /> Inspection By I X U)✓�— pate Inspection By LICA&I Date <br /> Fee Is"Due: Lf ANNUAtA_Y ❑ PER UNIT ❑ PER SITE EACH ❑ J11nuAfy t &Received By January 37 ❑ 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 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delive ed ? <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />