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Applications Will Be Processed When'ubr'nitied Properly Completed. Be Sure Tt44pplication. t� <br /> FOR OFFICE USE: APPLICATION r� 1g�g <br /> (For Non-Transferable, Revocable, Suspendable)® t <br /> pEJ � PunnP <br /> ENVIRONMENTAL HEALTH PERMIT �, ��A so F <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY � ( <br /> AppIicationisherebymadetotheSanJoaquinLocaIHealthDistrictforapermittoconstructand/orinstalIthev ri;�i�tiescribed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. J i <br /> Exact Site Address City/Town F_SCA�40' <br /> Owner's Name r-,4oP,eyyce 64 _ Phone <br /> Address Q �5 i <br /> � <br /> City - 1 , <br /> Contractor's Name License "o Business Phone <br /> Contractor's Address !v Emergency Phone .-e, <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL.ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 29 <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 Domestic Well I <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation �I <br /> ® DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing Lfl <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 /> PUMP INSTALLATION: . Contractor <br /> 5-� <br /> Type of Pump H,P. <br /> A PUMP REPLACEMENT: ❑ State Work Done t <br /> PUMP REPAIR: State Work Done ✓ L <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure f <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 forwhich 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." <br /> I will cal r a Grout Inspe pri o grouting and a final inspection. f J <br /> Signed X —— .Title:_ _ — raw` :. Date:/12'/ZZ T j <br /> (Draw Plot Pian on Reverse Side) I <br /> F R DEPA MENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date _ � 7-7 <br /> Additional Comments: <br /> Phase II Grout InspectioPhase III Final Inspection t� <br /> Inspection By Date Inspection By Date �QQ <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT 1XPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUECHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE S �� <br /> LESS k <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. - Issuance Date Mailed Delivered j <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95,201 <br />