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Applications Will fie Processed When Submitted Properly Completed. BeM To Sign TheApplication. 1 !�L; <br /> FOFj„°'DFFICE USE: APPLICATION OCT 2 1979 <br /> (For Non-Transferable, Revocable, Suspendable) pLUt;W <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUIN AW�LL <br /> HEALTH DISTRICT <br /> r(COMPLETE IN TRIPLICATE) WATER QUALITY <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 County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address [ City/Town <br /> Owner's Name �7 j Phone A36 <br /> Address City C A4 Y t <br /> Contractor's Name •�+ rte License# Business Phone j9�P•� D7 <br /> Contractor's Address Emergency Phone 4)-,q o <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes -4) No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN 11 RECONDITION❑ DESTRUCTION❑ �c <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR. <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <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 /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: tj <br /> PUMP INSTALLATION: Contractor . 1 <br /> Type of Pump H'P' \ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 0 State Work Done '� � 02, _ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth �1 <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 Joaquin 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." t <br /> i Contractor's hiring or sub-contracting signature certifies the following."I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 wil all fora Grout Insp tion p 'orFto grouting and a final inspec`on. �f <br /> Signed X Title: , e71! Date: � ,+�— <br /> (Draw Plot Plan on Reverse Side) <br /> FOR D ARTMENT USE ONLY <br /> PHASE Q <br /> Application Accepted By Date / <br /> Additional Comments: <br /> Phase 11 Grout Inspection / ' Pha I inai In tion �d00, <br /> Inspection By Date /� Inspection By to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r r/ <br /> FEE <br /> LESS <br /> PRORATION <br /> ! PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -7,9 7!t <br /> l <br /> Mailed Delivered <br /> Received by Date Receipt No. Permit No. 15suan a Da a <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE.,P.O.Box 2009. STOCKTON,CA 95201 <br />