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Applications Will Be ProcessedWhenSubmitted PropenyVomplelea. aeoure rvaiyn 1ticmmj114QIIV <br /> FOR OFFICE USE: APPLICATION SCAM0(For Non-Transferable, Revocable, Suspendable)ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY 1-2-e-­0acG—O.S �1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is \ <br /> made in compliance with San Joaqui unty Ordinance No. 1862 and the rules and regulations of the Sar�oaq�UIn Local Health District, <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> Address ' City <br /> Contractor's Name License# Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN 1:1RECONDITI DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Properly Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ 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 urface eal8stalled By: <br /> PUMP INSTALLATION: Contractor ` <br /> Type of Pu*AH.P. p <br /> PUMP REPLACEMENT: ❑ State Work Done ��1�. +�.h �R <br /> PUMP REPAIR: ❑ State Work Done— � <br /> DESTRUCTION OF WELL: Well Diameter _ Approximate Depth <br /> Describe Material and Procedure <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 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will. all for Grout Inspection prior toNrouting and a final inspectia : 7 <br /> I 3 G' <br /> Signed X Title: Date: <br /> YOW <br /> (Draw Plat Plan on R rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Q <br /> Application Accepted By `� U - Date -L* <br /> Ji Additional Comments: <br /> Phase Il Grout Inspection `� P a III Fi al Inspection <br /> Inspection By Date for Inspection B Dat ����- <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar 31 ❑ July 1 &Received By July 31 <br /> r REMIT <br /> BASE EXPLANATION 64LLING REMITTANCE AMOUNT DUE _ CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 5 tJ ST <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> IL 7 6 _ =Jy <br /> Received by D41. Receipt No. Permit No. Is uanc Date Mailed Delivered <br /> L APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9$20 <br />