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Applications Will Be ProcessedWhenSuumillea rruill jj;i 1 `it j1 <br /> FOR OFFICE U,FiE: APPLICATIONn Li <br /> (For Non-Transferable, Revocable,Suspendable) DEC <br /> ENVIRONMENTAL HEALTH PERMIT �UW <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY SAN jo�; , �� ��yy�.L.,� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thewo`H8AtT0es I �dd'ppppf��is..'applicationis <br /> made in compliance wit Sa Joaquin County Ordinance No. 1862 and the rules and regulations of the San P quintal W1 11 [9+st�ict. <br /> City/Town <br /> Exact Site Address <br /> i / Phone <br /> Owner's Name e A,,.1 <br /> AddressCity <br /> Contractor's Name License #�7 (1 p Bus' ess Phone <br /> Contractor's Address <br /> � Emergency Phone <br /> _. <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> — <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines f 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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <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 wil it for Gr rts�p ction prior to grouting and a final inspec. 1 -7—/� <br /> Signed X <br /> Title: Date: Ii2 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date v"= <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection hose ill Final Inspection <br /> i <br /> Inspection By <br /> Date <br /> Inspection B Date <br /> Fee 15 Due: ❑ ANNUALLY PER UNIT PER 517E ❑ EACH ❑ January 1 & eceived By January 31 ❑ July 1 &ReceivedliEMITuIy 3l <br /> EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> E <br /> BASDATE DATE REMITTED AMOUNT <br /> 4. O <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER All <br /> l� r7 �0 5s5g s <br /> Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> Received by <br /> SERVICES 1601 E.HA2ELTON AVE.,P.O.eaz 2009 $TOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/ <br />