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Applications Will Be Processed When Submitted Properly Complet'd.Jee$ur4Jo,�Siga�TWt ApiAicdtioln <br /> FOR OFFICE USE: APPLICATION <br /> 4 <br /> (For Non-Transferable, Revocable, SuspendableyC ?� " LL <br /> ENVIRONMENTAL HEALTH PERMIT �f r / <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN J��ti'i�1�. LC)t_'cL <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/dAYl��,�k '�1Rewbtkl�Iereiti-gescribed.Thisapplicationis <br /> made in compliance with San Joaqui County Ordinance No. 1882 and the rules and regulations of the Sanjoaquinn Local Health District. <br /> Exact Site Address City/Townf-�'�+ (�', �27 <br /> " Owner's Name a'++'t Phone *0 Cr <br /> Address City <br /> Contractor's Name License#9k OLVQ Business Phone 2- ` <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®r 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 /> TENDED USE TYPE OF WELL <br /> Y <br /> I <br /> 13 IN ENDED <br /> `� ❑ CABLE:�TOOL Dia. of Well Excavation - <br /> VDMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> MESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IGATION GRAVEL PACK Depth of Grout Seal <br /> THODIC PROTECTION. ❑ ROTARY Type of Grout <br /> POSAL OTHER Other Information <br /> OPHYSICAL 5, urface Seal Installed By: <br /> INSTALLATION: Contractor <br /> Type of Pump H.P. t <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 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." <br /> 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 /> I will all f r a ut Inspection prior to grouting and a final inspec <br /> t f <br /> Signed X '`-'^�-�-" Title: Date: f G r <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> ateAdPHASE I <br /> Application Accepted By "" ' Date— <br /> Additional <br /> ditional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> �' <br /> Inspection By f71 Date Inspection By /Y-� � Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> s $ Qa <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> `9 o B a <br /> Received by I Date Receipt No Permit No. I Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />