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Applications Will Be Processed When Submitted Properly Completed.`Be Sure To Sign The Application, <br /> FOR OFFICE USE: :APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) / <br /> �. .'ENVIRONMENTAL HEALTH PERMIT Pf &WELD 4 <br /> (COMPLETE IN TRIPLICATE) WATER.QUALITY` _ <br /> Application is hereby made to the San Joaquin Local Health District fora permit t6-construct and/or install the work herein described.This application is' <br /> 3 , <br /> made in compliance with San Joaquin Count Ordinance No. 1862 and the` I s an regulations of the San Joaquin Local Health District. <br /> Exact Site Address 00. / Cf City/Town <br /> Owner's Name Ce,61,�1?AA% Phone _ - <br /> Address inn! 0( City C D <br /> Contractor's Name �rl�f ./�-j � _ License#3Business Phone /'7 Ct <br /> Contractor's Address - `�' d /5'� '7i`/f/ / / Emergency Phone <br /> Is Certificate.of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No t <br /> TYPE OF WORK,(CHECK) NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONS 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 omestic Well <br /> INTENDED USE TYPE OF WELL I b�Excavationil <br /> INDUSTRIAL ❑ CABLE TOOL Ia. _— -; <br /> DOMESTIC/PRIVATE ❑ DRILLED -Dia. of Well Casing r U <br /> ❑ DOMESTIC/PUBLIC = ❑ DRIVEN Gauge of Casing (16 <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 /> } <br /> PUMP INSTALLATION: Contractor f 0 14 C- M .as <br /> Type of Pump_5 V R H.P. -5 <br /> PUMP REPLACEMENT: ❑ State Work Done Q "( <br /> PUMP REPAIR: ❑ 'tate Work Donee- <br /> DESTRUCTION OF WE Well Diameter C5 4 Approximate Depth <br /> Describe Material and Proceddre <br /> t 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. f <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 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 10 grouting and a final inspection. //JJ <br /> Signed X. Title: s li � Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By _ <br /> Additional CoCrlm�nts; # y T� ;� 4 0 <br /> hase+li Gro 1 Inspection ase Fina Inspection r <br /> Inspection By Date Inspection By Date / <br /> Fee Is Due: ❑ ANNUALLY 3 PER V ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i 8 Received By July 31 <br /> BILLING REMITTANCE $ <br /> REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOVNT#7UE -FCHECKED 1 <br /> AMOUNT <br /> O <br /> FEE <br /> LESS € <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by- - Date Receipt No. Permit No. fs uanceate_ Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 21109 STOCKTON,CA 95201 <br /> _ �p t <br />