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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> W_ (For Non-Transferable, Revocable, Suspendable) <br /> PU! &WELL� J <br /> ENVIRONMENTAL HEALTH PERMIT "" (( <br /> _ e <br /> (COMPLETE IN TRIPLICATE) 4 WATER QUALITY 0) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co my Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Addressy�J s• i4�`To/� / City/Town � �/� <br /> Owner's Name � �1 <br /> � 0AJ Phone�4ct- S341 <br /> Address �s.' 3 � I�.r ELLE City .17-ceK <br /> r Contractor's Name License#. 9V4Z Business Phone9— 0777 9 <br /> Contractor's Address R.. Emergency Phone TAL,",F <br /> Is Certificate of Workman's Compensation Ins nce on File With SJLHD? Yes X — No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ O <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tan z46-r <br /> lcr Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit zxo O[her { <br /> Property LineA49215`Private Domestic Well Public Domestic Well'N. r INTENDED USE USE I TYPE OF WELL <br /> r' ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation �a /➢w <br /> -- <br /> W'DOMESTIC/PRIi VATE ❑ DRILLED Dia. of Well Casing /r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> r <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grqut Seams <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Graut q s.4e,� Sy4it1� _ <br /> ❑ <br /> DISPOSAL � �❑ OTHER Other Iriformafion <br /> ❑ GEOPHYSICAL4 [ SurfaceSpa InstaNed By: <br /> PUMP INSTALLATION: i`Contractor <br /> jType of Pump_.. H.P. <br /> PUMP REPLACEMENT: State WorklDone i <br /> i <br /> PUMP REPAIR: 1iState Work Done <br /> DESTRUCTION OF WELL: Well Diameter ` ' Aptroximate Depth;, <br /> '7. <br /> Describe Descre Matrial and Procedure � '� -• ('ijt �.� rJl ; <br /> I hereby.certify that I have prepared this application and that file work will be done)n accordance with[[San Joaquin County s <br /> ordinances, state laws, and rules and regulations of thexS4 Joaquin Lacai Wealth District. ' <br /> I. Home owner or licensed agent's signature certifies the following:"I certify that in the performance of t 1Rework for which this permit <br /> 1 is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> t 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, l-shall-employ-personsFsubject to workman's compensation laws of California." J <br /> t i 11 call for a Grout1nspectiQu prior to grouting and a final inspection. <br /> Signed X - f 4 Titie /�4 � Date: <br /> (Draw Plot Plan on Reverse Side) <br /> t FOR DEPARTMENT USE ONLY 7 <br /> PHASE <br /> Application Accepted B Date <br /> Additional Comments: ° <br /> i P e I Grout Inspection -7 1 t h se 11 Final pection/ <br /> Inspection B Date mt.—Inspection Datel <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> i BILLING REMITTANCE $ <br /> 5 BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i- - OTHER ,.- _ .. . - •• '__ .-. _ ,. -__ - w <br /> Received by Date i Receipt No. Permit No. Issulance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: :riENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,CA 95201 <br />