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nFrNrr..au.ana rnn verr�a.eaasu rnren au.iur..eear rra.}.err� a..vu.t..e.e.a vco}+r� ryyreyrr .ne•+}�prwou�n. <br /> FOii OFFICE USE: 'APPLICATION <br /> (For,Non-Transferable; Revocable,•Suspendabla) <br /> ENVIR014MENTAL HEALTH" ERMI <br /> .,., QUALITY <br /> y <br /> (COMPLETE IN TRIPLICATE) � "- -WATER Q <br /> Appl ication is hereby made to the San Joaqui n Local Health D istrict for a permit to ccnstruct and/or inslrlll the work herein described.Th is application is <br /> made in compliance with an oaq ty r�d"oance No. 1862 and therrules and regulations of the San Joaquin Lo ai Health District. <br /> Exact Site Address �j� � �, CityfTown, 'Fd /�j <br />:.::Owner's Name I'Ga G-L�} d > Phonq _!_474-.—,1'�! <br /> Address <br /> Contractor's Name � � � License# Bu9i(tei;g ItUtje 1 <br /> P✓h/l/�* N <br /> Contractor's Address � '�"��� Emergency.Phone "_. 49--� � <br /> Is`Certificate of Work man's.Compensation'lnsurance on File With SJLHD3 . "'Yes No , <br /> °TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ ,y <br /> WILL"CHLORINATION ❑ WELL 'ABANDONMENT ❑ OTHER ❑ PUMP'INSTALLATION W PUMP REPAIR K� .- <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy :. <br /> Sewage Disposal Field Cesspool/Seepage Pit ...— Other <br /> 7:1 .property Line rPrivate.Domestic.Well Public Domestic Well <br /> INTENDED-USE :,:":, ..TYPE OF W-EL11L <br /> . - <br /> © INDUSTRIAL ❑ CABL-E TOOL:. DIa,.'of"Well Excavabotti� <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED w _Dia.`ot Weil Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK ':Depth of Grout.50a1 <br /> ❑,CATHODIC PROTECTION ❑ ROTARY -Type of Grout__- <br /> ❑ DISPOSAL ❑ OTHER Other Information .- <br /> ❑ GEOPHYSICAL Surface Seal Instated By:- <br /> :PUMP INSTALLATION: Contractor <br /> ; s... Type of Pump N.P. <br /> PUMP REPLACEMENT;; L'State Work Done <br /> > a n <br /> PUMP REPAIR: 5tate..Work Donee --- -- -- v <br /> DESTRUCTI{1N OF•WELL-.: _Well Diameter __� Approximate Depth.- <br /> Describe-lMaterial <br /> epthDescribe-lMaterial and Procedure <br /> I hereby cert}ty.that I have prepared this application and-thetL-the-work will be dodo til accordarice with;San Joaquin County i <br /> ordinances, state taws, and rules and,regulations of'the San Joaquin Local Health l)lstrict. i <br />- .. Home owner orlicensed agent's signature certifies the following:"I certify that in the llorformanro uI thework for whichthispermit <br /> is issued, I shall not employ any person in.such manner as to become subject to woikman's compensation laws of California." <br /> Contractor's hiring or sub-corrfractingsigcature certifies the following:"I certify that tri the performance of the work forwhich this <br /> permit is issued, I shall employ person's sW*ect to,workman's-compensation laws-.of California ;r.=- i <br /> Twill call for a Grout Inspection prior to grouting ano:a.final.inspection:,_`,::, " <br /> Signed X I? °a 9 u, ::;_Title: Date: J '7 P <br /> (Draw Plot Plan on Reverse Side) �Y <br /> FOR D PARTME -U ONLY <br /> -PHASE <br /> .Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 6rout Inspection phase III Final Inspection <br /> Inspection By -Date Inspection By. Date <br /> Is Due:`❑.,ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑January i &Received By January 31 ❑ July 1 &Received By July 31 ! <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE ExPLANATION DATE DATE REMITTER AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEELe <br /> r LESS / C <br /> PRORATION � III <br /> PLUS <br /> PENALTY O q <br /> OTHER <br /> f - <br /> OTHER <br /> Received by '` Date ReceiptNo. 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 95201 J <br />