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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Wppficatlon 2 E U <br /> FOR OFFICE USE: <br /> APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) PLMPI&W� f _ <br /> M 0 088 3 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �• 1 `.r. e.r t <br /> (COMPLETE IN TRIPLICATE) WATER QUALITYF / _�-�" �� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructand/or installthe work herein dekll1tVebw'iThjsW-ffii� tj'r3Ts <br /> made in compliance with San Joaquin Count Ordinance No. 1862 d t rules and regulations of the San Jo uin Local Health District. M1 <br /> AI �J City/Town � � <br /> Exact Site Address c <br /> Owner's Name Phone ' <br /> Address City' ' <br /> Contractor's Name "� License ? ��'' Business Phone 7 <br /> Contractor's Address Emergency Pho (5- <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes — No <br /> I TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 00 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR �14 <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy >� <br /> Sewage Disposal Field Cesspool/Seepage Pit" Other <br /> j Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 4:• ❑ CABLE TOOL Dia. of Well Excavation <br /> IK DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC Cl 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: <br /> l PUMP INSTALLATION: Contractor <br /> . .._1 <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 10 State Work Done . ` <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth__G,3 <br /> Describe Material and Procedure <br /> L J <br /> I her certify that I have prepared this application and that the work will be done ih accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <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 w' all for a Grout pe n prior to grouting and a final inspect' <br /> Signed X <br /> Title: Date: <br /> (Draw Plot Plan on R verse Side) <br /> FOR DEPARTMENTIUSE ONLY <br /> PHASE I ,- 93 <br /> Application Accepted By Date <br /> s e., �` fld. <br /> Additional Comments: <br /> P else II Grout Inspection r PhIII Final Inspection <br /> " <br /> ACh C4 <br /> Inspection By Date Inspection By s <br /> Date <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH ElJanuary i &Received By January 31 ❑ July 1 &Received By July 31 <br /> - REMIT <br /> s BABE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED ' <br /> DATE DATE REMITTED AMOUNT <br /> FEE i.t1 <br /> k LESS i <br /> PRORATION <br /> PLUS <br /> PENALTY 1 <br /> OTHER <br /> OTHER Z <br /> till VP <br /> Received by �'�'�� Dat - Receipt No.;. Permit No. Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN LL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE P.O.Box 2009 STOCKT{1°' - <br />