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FOR OFFICE USE: ^APPL,ICAMN <br /> T,_z� <br /> _,»,l(For Non-Tranilotableillevocabie;Suspendable). <br /> 7' 1rNVIRONIVIRNTXL"'HEA'L'TH.PERM1T <br /> E1TW UALITY _ <br /> (COMPLETE IN TRIPLICATE) I Y's_ <br /> Application is hereby made to the San JoaquitnLocal Health,Distric.Ifo Umrmlttoconstruct.and/or install the work herein"described.This application is <br /> made in compliance with San Joaquin ounty dinance No: 1802 nd the .riples and rWulationS of the San�Joaquin Local Health District. - <br /> g ... <br />!i Exact SiteAddre,ss. I ; <br /> � fa •�Y� _;_, City/down � <br /> k Owner's Name ` O �-- - - Phone J�f > <br /> 1 Address " .. City. 5 <br /> Contractor's Name r L �L �^�L e e# =>L��'c�c1�"'business Phone^° '� — E "Z <br /> r <br /> Contractor's Address + _. __. f=lt{ergency'Phone /� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? r Yes_ i No' <br /> TYPE OF-WORK {CHECK): NEW WEL DEEPEN d RECONDITION C1 -DESTRUCTION❑ <br /> `WELL=CNL'ORiNATfON ❑ WELLT=A'B'ANDO11 MENT © OTHER 0 `''`PUMP`'INSTALLATION 13 "- PUMP'REPAiR❑ <br /> REPLACEMENT❑ No <br /> Sewage <br /> p <br /> DISTANCE TO NEAREST: Septic Tank. Se � Sewer Lines Sd Pit Privy / <br /> Sewage Disposal Field NO _.-_-- Cesepool/Seepage Pit 012.Jo Other <br /> y Property Line Private DSmestic Welt _.. Public Domestac"Well O� <br /> INTENDED USE .. k TYPE OF WELL <br /> 11 INDUSTRIAL ABLE TOOL pia. of Well Excavation <br /> iiia. of Well Casing <br /> O:MESTIC/PRIVYATE � „..-,.. `.� DRILLED - . • <br /> f ❑ DOMESTIC/2UBLIC -DRIVEN„ Gauge of Casing s ► <br /> f + - <br /> ❑ "''IRRIGATION '❑"'GRAVEL.PACK Depth of Grout Seal, <br /> 11 CATHODIC PROTECTION F ROTARY - Type of Grout <br /> ❑ DISPOSAL i .. JI]•OTHER _ w { Other-Information <br /> ❑ GEOPHYSICAL _ .Surface_Seal'Installed By: <br /> n Al E AC <br /> 4 PUMP INSTALLATIQN:'>; Contractor _ <br /> f ,Type of Pump -.___ •H'P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State.Work Done ._ <br /> DESTRUCTION OF WELL: �'- - Well Diameter—...... Approximate Depth <br /> I _ - ­Describe:Material an-I Procedure <br /> ' 1-hereby certify that"i have pr pared 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 Joaklluin Local Health District:! # <br /> 'Home:owner or licensed agent's signature certifies ltle following;"I certify.that,in the performance of the work for which this permit <br /> _ ',.is issued,"f shafl:not'"employ any person in such manner as to become.Subjectio"workman's"compensation laws of California." ,- <br /> lliea the Idllo+king:"I certify that r <br /> t in the perfgrmance of the work fowhi+h this <br /> Contractoes.hiring or-sub-contt.acting signature cert <br /> permit is.issued,1 shafl,.employ persons subject to workman's compensation laws of California"';,: <br /> I will tali for a Grounap dio rio�Iqroulling and a Ileal inafiectian. 't •- ' " <br /> z <br /> Signed X Title. __ Date: <br /> y. (Draw-l?lol Plan on Reverse Side) <br /> R ;DEPARTMENT USE ONLY <br /> PHASE:I <br /> Application Accepted.By ---"!'- - Date./ <br /> Additional.Comments: <br /> ! Phase It Grout Inspection Phase III Final Inspection <br /> Inspection By i Date Inspection By Date <br /> + <. 'l <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE - ,L'SI EACH I January 1 &Received By January 31 I] July-14 Received By July 31 <br /> REMIT <br /> BASE i .;:EXPL"ANATION -,BILLING '-REMITTANCE •$� "�-AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 443 dro /7 7/ <br /> .. LESS <br /> k PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receiv d by Date Receipt No. PermtItJo- - Issuance Date Mailed "- Delivered <br /> 1 <br /> i PPLICANT—RETURN AL COPIES TO: ENVIRONMENTAL EALTH MITISER ICES 16111 E.HAZELTON AVE,,P.O.Box 209 STOCKTON,CA 95201 <br />