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Applications WIII 6e Pr a sed When Submitted Properly Completed. Be Sure To Sign The Application. ' <br /> FOR OFFICE USE: APPLICATION <br /> k (For Non-Transferable, Revocable,Suspendable) ' <br /> ENVIRONMENTAL HEALTH PERMIT FUME&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is ' <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin ocal Health District. <br /> Exact Site Address.#75�– -1 ?� City/Town <br /> Owner's Namelv__Ps.T ZR r/ o'n_9_C ow e Phonely <br /> _ <br /> Address199 <br /> City , <br /> Contractor's Name License# , Business Phone <br /> Contractor's Address( A./ Emergency Phone �.} <br /> Is Certificate of Workman's Compensation Insur nce on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 0" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION Q— PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field 2!VZ f Cesspool/Seepage Pit A-4--t Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation j <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing € <br /> 9-50MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing r. <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout t <br /> ❑ DISPOSAL ❑ OTHER Other Information { <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ) <br /> PUMP INSTALLATION: Contractor I <br /> Type of Pump AM vep <br /> PUMP REPLACEMENT: ❑ State Work Done t <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 /> 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." I <br /> I will call for a Grout Ins coon prior to grouting and a final inspect'on. <br /> Signed X Title: Date: /Z <br /> ;. (Draw Plot Plan on Reverse Side) <br /> i. <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �n <br /> Application Accepted By f`-�✓`�1°L�._ _ Dates' <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By �^-�--� Date t <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received Ry July 31 <br /> BILLINGREMITTANCE $ - REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED' <br /> O� AMOUNT <br /> FEE i <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> } <br /> OTHER <br /> S �- <br /> Received by Date Receipt No. Permit No. I uanc Date Mailed Delivered. fi <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES. 1601 E.HAZELTON AVE P.O.Box 2009 STOCKTON,CA 95201 <br />