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— plications Will Be Processed When SubmittedPropertywmp—w— �—,- '3K I FOpv <br /> APPLICATION L <br /> FOR OFFICE USE: (For Non-Transferable, Revocable,Suspendable) jor,01iJIN ti <br /> ENVIRONMENTAL HEALTH pERMI SAN HEATH D151 �,�,T <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made to the San JoaquinL°rdinance No. 1862andrict fo(a pthe uses and regulations oftthe San Joaq111,uinlLocal HealtthTDisthis ripct. I-anon is <br /> made in compliance with San'Joaquin County 6 City/Town <br /> I Exact Site Address r <br /> Phone <br /> Owner's Name J �C City <br /> Address — ��--�-?�! Business Phone <br /> j' f�/ License# -� - <br /> i <br /> Contractor's Name Emergency P one +i <br /> Contractor's Address No <br /> k f Workman's Compensatio Insurance on File With SJLHD? Yes UCTION❑ <br /> f Is Certificate o �+ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTR <br /> WELL. El OTHER ❑ PUMP INSTALLATION 13 PUMP REPAIR❑ <br /> WELL CHLORINATION❑ <br /> + REPLACEMENTS Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Wel; <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> [3 CABLE TOOL Dia. of Well Excavation 3 <br /> ❑ INDUSTRIAL Dia. of We;1 Casing - { <br /> �- DOMESTIC/PRIVATE 3;1 DRILLED <br /> DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC t'�❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ' Type of Grout V <br /> ❑ CATHODIC PROTECTION ❑ ROTARY ,. <br /> I ❑ OTHER Other Information <br /> 'f 11DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> I PUMP INSTALLATION: <br /> Cntractor H P <br /> iLyo <br /> pe of Pump <br /> PUMP REPLACEMENT: State Work Done <br /> I PUMP REPAIR: <br /> 11 State Work Done Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> repared this application and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have � <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> in the performance of the tities the work <br /> f� California." <br /> r which this permit <br /> becomelfalaws of <br /> Horne owner or licensed agent's signature <br /> cer <br /> is issued, I shall no poY such manner as to certify <br /> subect to workman's compensation <br /> i <br /> ormance of the work far which this <br /> Contractors hiring or sub-contracting signature certifies the following:"I certify that in the perf <br /> permit is issued, I sha;1 employ persons subject to workman's compensation laws of California." Qr <br /> �— t T <br /> I will call for a Grout Inspection prior to grouting and a final inspection. _ �Date. <br /> Title: <br /> Signed K ` <br /> (Draw Plot Plan on Reverse Side) <br /> F R DEP TMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: P se III Final inspection <br /> Phase 11 Grout Inspection Date <br /> t Inspection By <br /> Date Inspection By <br /> PER UNIT ER SITE ❑ EACH ❑ January 1 &Received y January 31 El 1 R ReceivedREMITu y <br /> 31 <br /> Fee IS Due: ❑ ANNUALLY ❑ <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ETHER 'T - - <br /> - Receipt No. Permit No. <br /> Issuance Date Mailed Delivered <br /> Received by Date 1661 E.HpZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />