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. tapprwassys�a vm ocrwa.coa ..a. .ay......a... . <br /> FO1i OFFICE USE: APPLICATI. <br /> .,.,....r.... <br /> (For-Von Transterall:ii # dable) <br /> ENVIRONMENTAL WTH'PIIITf 19 � <br /> WQIER"QV �Ati <br /> (COMPLETE 1N TRIPLICATE) <br /> Application is herby"madeto the San Joaquin Local Health District fora.permitto construct andJ�gr(T�U�A1y1�`t berelil described.This application irk <br /> p ' ' y� ltfler aq <br /> made in compliance!w' S n oa�,t Cou�Ordinance No.•1862-and the rufes an� la• f an oa taro Eocal eafth District: <br /> Exact Site Address v'� /�► �P ity/Town / �� <br /> �c� �Lg � O'b Ut? J -� Ph ne 11 <br /> Owner's Name o <br /> Address l �' City <br /> Contractor's Name - �' v 1`7 `'"° License#U 373 Businessf?hai18 <br /> Contractor's Address Emergency Phones <br /> Is Certificate of Workman's Compensation-insurance on File With SJLHD? Yes / f �1 <br /> TYPE OF WORK (CHECK): '-NEW'WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION© <br />""' WELL CHLORINATION ❑ "WELL ABANDONMENT ❑ 'OTHER'91' '.PUMP INSTALLATION© ­--PQMP 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,Domusft Well Public Domestic.Wall.__. <br /> INTENDED USE -TYPE OF WELL _ <br /> ❑ INDUSTRIAL _ _13 'CABLE•TO.OL' Dia_of-Well ExcaGati0ni- _ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing. _ <br /> -❑ DOMEST.IC/PU$.LIG,;,- n ❑ DRIVEN ,Gauge-of Casing _ <br /> ❑ IRRIGATION ;": ❑ GRAVEL PACK , ',js Depth of;Grout Seat _. <br /> ❑ CATHODIC PROTECTION ❑ ROTARY _Type of Grout - <br /> ❑ DISPOSAL ' ❑ OTHER Other Information raR <br /> _ ❑ GEOPHYSICAL '-Surface Seal Installed By: <br /> PUMP.INSTALLATION. :._.Contractor —_.. <br /> Type of Pump H.P._... <br /> PUMP_REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR,:,,,.,;;.::, 21 State Work 3Tone 7,0 - <br /> DESTRUCTION OF WELL: Well Diameter /� Appioxlmate Depth <br /> Descril*!Material and Procedure <br /> I -hereby certify=that I have prepared-,this application-sand that the w.orke will.be done in accordRince wish San Joaquin-County <br /> ordinances:"-state laws, and-rules and-regulations ofjhe ap JoaquiRt,Local Health District. <br /> Home owner:orlicensed:agent's•signature certifi,esthe-following:,'I-certify that in the performatwo of the woik forwhich this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workrnari's Cempensatloh laws of.California." <br /> -Contractor's hiring orsub-contracting signature certifies the following:"I certify that in'the perfornoanceof ittework••forwhich this <br /> permit is iss I shall emp y p rsons subject to workman's compensation laws of California." .. <br /> wif c G ut tn4, <br /> spec on prior to grouting and,ajinaf•inspectio <br /> Signed X Title Date' <br /> (Draw Plot Plan on Ridverse Side). <br /> YFOR EPART NT USE ONLY <br /> - PHASE <br /> Application Accepted By �9 '2'�"` ____-__-- Date <br /> Additional Comments: <br /> p e 11 Grout inspection ha a Iii Flhal Ihspectfa <br /> I <br /> Inspection-By- - Date :,Inspection By Date <br /> i Fee Is Due: ❑ ANNUALLY-1- ❑ PER UNIT •41ER SijE .13-EACH -'❑ January,l &Received By January 31 ❑ Juiy-1-&Received By July 31 <br /> REMIT <br /> 'BASE 'EXPLAN ION BILLING. ',,',,REMITTANCE $ - 'AMOUNT DUE CHECKED <br /> --DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> - OTHER <br /> Received by - Date Receipt No. ``i'erm3t'No, issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br /> 1 . <br />