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Applications Will Be Processed When Submitted Properly Completed. Be Sur i1Tfae�ppli tiff. C� <br /> FOR OFFICE USE: APPLICATION- <br /> (For Non-Transferable, Revocable,Suspendable) j/b1 &�,p/ f-L <br /> ENVIRONMENTAL HEALTH PERMIT SAN <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY � oI� 'j0v <br /> Application is hereby made to the San Joaquin Local Health District fora per mit to construct and/or install the v ork"h�Yeinf1),hscr4 #,� es applic tion is . <br /> made in compliance with San Joaquin ount Ordinance No. 1 Ae rules and regulations of the San.Joaquin Local Health District. <br /> Exact Site Addre 1 �$ �� C' y/Towne- f`n b <br /> Owner's Na eTt ►YIU l Phone{a <br /> Address ) L - City- <br /> Contractor's Name License Business P one; <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compens ion Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑- DESTRUCTI.N <br /> WELL CHLORINATION 11 WELL ABANDONMENT 11 OTHER ❑ PUMP INSTALLATIO PUMP REPAIR❑ <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 Public-Domestic Well ,r �•"r <br /> TENDED <br /> NDED USE z- TYPE OF WELL <br /> IND STRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing <br /> ❑ IRRI ATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CA rHODIC PROTECTION ❑ ROTARY Type of Grout <br /> i <br /> 101 DI POSAL ❑ OTHER Other Information <br /> 11 <br /> OPHYSICAL Surface Seal Installed By: <br /> P INSTALLATION: Contractor O s <br /> b <br /> Type,Of Pump H.P. <br /> PUMP REPLACEMENT: State Work Done �- <br /> PUMP REPAIR: ❑ State Work-Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 1r <br /> Describe Material and Procedure <br /> i <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-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 /> F <br /> Fcallr a Grout Inspection r to gr ingan final inspection. z <br /> Signed X - Title:_ <br /> Date:-_ <br /> (Draw of Plan on Reverse Side) i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I p �a <br /> Application Accepted By <br /> Date <br /> Additional Comments: <br /> f , Pha out Inspection <br /> tasp7lil Fiipl Inspection <br /> Ipspection By--==�` Date Inspection By Date 1P__-20J1 <br /> Fee IS Due: ❑ ANNUALLY` ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January.1 &Received By January 31 '❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE D REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ' OTHER <br /> • 1���3w Paj l`� � <br /> Received by Date -Receipt No. Permit No. Issuaince 05t& Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKY'ON,CA 95201 <br />