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` Applications Will Be Processed When Submitted Properly CompleteMp ij-FeTbSign TheApplicaton. <br /> FOR OFFICE USE: APPLICATION 1 OODU <br /> (For Non-Transferable, Revocable, Susp le) 1,1� �7 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> PULP&WELL Q <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ,CCH ID11 I �c1VT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or InMITthe work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �l'f SlJ geF �/lfE Q - City/Town�y��pC� yU��S// <br /> Owner's Name � / .e?��s Phone <br /> Address Z� ys0 City <br /> Contractor's Name C!1 Ld/ License# Business PhoneT // <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 ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> i REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ®�/ Sewer Lines Pit Privy <br /> f Sewage Disposal Field Cesspool/Seepage Pity .. Other <br /> Property Line Private Domestic Well Public Domestic Well Z <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 /> 09 IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> i ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor i?�/I�'/19e_1_0_d9WZP ew j1 <br /> Type of Pump 7/,fb %�'1 � _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> �i <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:1 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 /> l Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this .: <br /> f permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X / 0fl r Title: Date: �����•'�15 ® ; <br /> r (Draw Plot Plan on Reverse Side) <br /> r <br />' FOR PARTM NT USE ONLY <br /> i PHASE <br /> Application Accepted By D� Date <br /> Additional Comments: i <br /> Phase N Grout Inspection Phase III Final Inspection { <br /> i Inspection By Date Inspection By Date <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 /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> - <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY I <br /> OTHER <br /> OTHER �r <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009- STOCKTON,CA 9520 <br />