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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign APPLICATION <br /> (For Non-Transferable L <br /> � 4` L <br /> FOR OFFICE USE: 0. <br /> ' <br /> a, RevocableSuspendable) ttEIL5 1981 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE-IN TRIPLICATE) WATER QUALITY SAN JOAQUIN LOCAL <br /> 4 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/o�,r install the work,herA@5er<itWd.Df&1aR°I,i?,_q'Rion is <br /> made in compliance_ with San Joaquin aunty rdinance No.7$6 nd the rules and regulations of the San Joaquin Local Health District, <br /> Exact Site Address . �" City/Town <br /> IZ <br /> -- <br /> Owner's Name - 'o`Cr'� '� ' —• <br /> Phone <br /> Address .4"n,6 -i£:.rY_ <br /> /�c�,� City <br /> Contractor's Name a ` d C ' ' License#�/A J© Business Phone ';�.�EQ <br /> Contractor's Address 613 lh�J JJ! ;' Emergency Phonert S yr d.�'^•£' '^ r t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes a�f Not <br /> TYPE OF WORK (CHECK): NEW"WELL❑ 'DEEPEN ❑ RECONDITION❑ "DESTRUCTION❑ <br /> rt WELL CHLORINATION ❑ ,WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR 13 - <br /> REPLACEMENTO <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit1­,P'--Other- <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE 'TYPE OF WELL <br /> ❑ INDUSTRIALD CABLE TOOL. Dia. of Well Excavation <br /> 9 DOMESTIC/PRIVATEd ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK r Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: � State Work Done <br /> PUMP REPAIR: s ❑ 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 Joa_quin.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 forwhich this <br /> r permit is issued, I shall employ persons subject-to work'iman's compensation laws of California." <br /> i r r <br /> 1 will c a Grout In flan to grouting and a final inspectio - <br /> Signed X Title: bate <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I <br /> Application Accepted By Date- <br /> Additional Comments: <br /> Phase 11.Grout inspection inal Inspection ! <br /> Inspection By Date Inspectiony` Date <br /> Fee Is DUE: ❑ ANNUALLY +: El PER UNIT ❑-PER SITE ❑ EACH [] January t ceived By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION" = BILLING - �.REMITTANCE $ - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS v s _.w . _. <br /> PENALTY <br /> 'OTHER .� <br /> OTHER �- <br /> 4/0 <br /> Received by Date. .Receipt No. Permit No. i ' Issuance Date. ailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O—'Box 2009 STOCKTON,CA 95201 <br />