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f' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r FFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) <br /> LL <br /> 15, <br /> ENVIRONMENTAL HEALTH PERMIT- 1WATER QUALITY <br /> (COMPLETE IN TRI LIGATE) <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 CourtygOrdin nce No. 1862 and the r s and r gull tions of the San Joaqui Local H al h District. <br /> Exact Site Address _. i. �` {r City/Town <br /> Owner's Name E Phone " <br /> Address �' City <br /> ' <br /> License 4&p2_; 39Business Phone 5 <br /> Contractor's Name <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on ile With SJLHD? Yes_jam No <br /> TYPE OF WORK (CHECK): NEW WELL Er DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> a'h <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR <br /> REPLACEMENT❑ (/1 <br /> DISTANCE TO NEAREST: Septic Tank 0 Sewer Lines_/4) Pit Privy z <br /> Sewage Disposal Field Cesspool/Seepage Pit Other f; <br /> Property Line Private Domestic Well Public Domestic Well „✓ <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 121 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 /> ❑ <br /> GEOPHYSICAL ' Surface-peal Installed By. # <br /> PUMP INSTALLATION: Contractor F <br /> Type of Pump H.P. I <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Inspection.prl to grouting and a final inspection. _ <br /> Signed X r Title: Date: <br /> Z (Draw Plot Plan on Reverse Sid <br /> I <br /> FOR DEP TMENT USE ONLY <br /> PHASE I t- 3 5" 3 7 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> 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 /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED " AMOUNT <br /> FEE <br /> LESS 7 <br /> PRORATION <br /> 4eceiv <br /> - <br /> 6,21-3 <br /> Dae Receipt No. Permit o. Issua a Date Malted Delivered <br /> 'AETURN-AL-L-COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 9520 <br />