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applicationsWill Be Processed When Submitted Properly CompletL Sure- T-o h"---I <br /> t� �ign T — <br /> EFOROFFICE USE: APPLICATION 4 llation. <br /> (For.Non-Transferable, Revocable,Suspendable) I- <br /> J' H C)N U0 I- <br /> &WELD <br /> ENVIRONMENTAL HEALTH PERMIMN <br /> tt HEALTH D1STR� <br /> I {COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora 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 ajd regulations of the San Joaquin Local Health District. <br /> Exact Site Address T C7<'. City/Town JEg C <br /> t Owner's Name 1 A <br /> k Address I] EI <br /> s r <br /> t Contractor's Name <br /> F License#Q1._J n Business Phone — d <br /> Contractor's Address n Emergency Phone 0,0 <br /> i. Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Z" No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ it <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 1Z ) <br /> : Se <br /> DISTANCE TO NEARESTtic Tank " <br /> P Sewer Lines PitPrivy <br /> i Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE [ TYPE OF WELL <br /> ❑ INDUSTRIAL El CABLE TOOL Dia. of Well Excavation _ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing DO <br /> i. <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N: <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout [/y <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: ` <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. 3• <br /> PUMP REPLACEMENT: 12 State Work Done S <br /> PUMP REPAIR: ❑ State Work Done 2,v4e J <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 Al for a Grout In actio` prlor o-grouting and a final inspectili - <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) f <br /> F R DEPA TMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Zp,14 <br /> Date y <br /> Additional Comments: <br /> Phase II Grout Inspection 8 <br /> as II Final peclion <br /> Y <br />. Inspection By Date /✓� P Inspection By bate �� /� p <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH El January 1 &Received By Januar Y 31 ❑ July 1 &Received By July 31 <br /> I BILLING REMITTANCE REMIT h <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> DATE GATE REMITTED <br /> } e-� AMOUNT <br /> FEE xf• �J L . <br /> LESS <br /> PRORATION + <br /> PLUS <br /> PENALTY. <br /> OTHER i <br /> i <br /> OTHER <br /> Received by Date # Receipt No, Permit No Issu nce ate Mailed Delivered <br /> APPLICANT—RETURN"ALC COPIES TO: ENVVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P.O.sox 2009 r. .sTOCKTON,CA 452D1 ` ~ <br />