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Applications Will:tae Processed When Submitted Properly Comp�e�eJ. � S e oSign The App n. <br /> FQS��E USE: APPLICATION 5� <br /> (Fpr hon-Transferable Revocable, SL ¢rrdable�� <br /> ENVIRONMENTAL HEALTH PERMIT Pr, � L !CAL <br /> MP&WELL <br /> ;; WATER QUALITY SV'l <br /> (COMPLETE IN TRIPLICATE) 4 "5 _ t4 <br /> nd!o <br /> Application is hereby made to the San Joaquin Local Health District for a permit to constructaI hework herein described.This application is <br /> made in compliance with San Joaquin Count OrdinancejNo. 18U an the rules and regulations of the San.Joaquin�Local HealthDistrict. <br /> Exact Site Address 44 6Z \�, _ City/Town <br /> Owner's Name4;�_. Phones <br /> Address J City <br /> j Contractor's Name d Nn License Business Phone s 1 .31 V t <br /> Contractor's�Add@ &V j�i 5T�.;4toQ it 13 Emergency Phone 1 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No oQ <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ 'PUMP INSTALLATION ❑ PUMP REPAIRS <br /> I REPLAC>rMENTB_ �i J <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines / Pit Privy <br /> F Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> y INTENDED USE TYPE OF WELL f <br /> { ❑ INDUSTRIAL it ❑ CABLE TOOL Dia. of Well Excavation / * <br /> �MESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC i ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 0 ❑ GRAVEL PACK Depth of Grout Seal �- <br /> ❑ CATHODIC PROTECTION D FTnTARY Type of Grout `r <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL M Surface Seal Installed By: <br /> PUMP INSTALLATION: pi Contractor+ N ��" <br /> Il: <br /> Type of Pump f:> H.P.- <br /> PUMP REPLACEMENT: li ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRU�TIOONN OF WELL: Well Diameter Approximate Depth <br /> DEW <br /> �b Describe Material and Procedure <br /> l c cr+t � C� <br /> t I hereby certify thatA have prepared this application and that the work will be done in acc dance with an 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 fallowing:"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 /> 1 permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Gout Inspection prior to grouting and a final inspection. <br /> Signed <br /> Signed X _ Title:`���, Date <br /> (Draw Plot Plan on Reverse Side) <br /> a. <br /> FOR DEPARTMENT USE ONLY <br /> I PHASE I ,I <br /> Application Accepted By O� Date <br /> Additional Comments: Q <br /> Ph a Grout I pection ` Phasi l anal I pection <br /> Inspection By Date Inspection By rr Date <br /> Fee Is Due: ❑ ANNUALLY it ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January'l &Received By January 31 V❑ July 1 &Rece;ved By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE: EXPLANATION EE <br /> DATE DATE REMITTED <br /> AMOUNT DUE CHECKED <br /> F AMOUNT <br /> FFEE � ..- <br /> LESS <br /> PRORATION ¢ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �I <br /> Received by D e I Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520-1 -, <br />