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Applications Will Be Processed When Submitted Properly Completed..Be Sue i� IR pU ZnL <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) j <br /> iON O <br /> - ENVIRONMENTAL HEALTH PERMIT P &WELL s <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN JA �SIIL j <br /> Application`IsherebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/or install the vKIRI�reAi cQ1n' be'tl�}g.gTisapplicationis J <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> a-cqExact Site Address !� q S� ltf- City/Town I0A! C,19-, <br /> I Owner's Name It lb AI"4 ` Al r L11e-11 Phone <br /> Address 2YSCity C..- )A,) I <br /> Contractor's Name /(/ � License# yC.C75� Business Phone 4 <br /> 0 <br /> Contractor's Address 21 LJ -M&/Net 0o4 f�� Emergency Phone J Q s Y-,-Jr- <br /> Is <br /> -,J Q <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I 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 TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Y. 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 Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump I H.P. <br /> PUMP REPLACEMENT: � State Work Done�fa.ae.- oim- .Ort.tii a'»>AYAzll.,') z 1_+P srt,6e:je+-s i; [* <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. i <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspections. <br /> Signed X - Title: r'�-% [!r Date: <br /> (Draw Plot Plan on Reverse ide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection P ase III Final Inspection r / <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: C3ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 & ec ed By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED Af AMOUNT <br /> FEE i <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0(0 O& - 10-so y _s <br /> Received by Date Receipt No. Permit No. "6 r issuance DatMaii€d Delivered �~ <br /> r <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH�PERMIT/SERVICES -RAZELTON AVE.,P.O.Box 2009 ` STOCKTON,CA9 `*- <br />