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t -= Applications Will Be Processed When Submitted Properly Completed. Be 5 r�Ii, o ry nyes►FFitc�rvE 1 1 I 1 <br /> FOR �,��-sE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendabl MAR 11 &WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> C :i. ;IIfATER QUALITY SAN J�GAQU I N �O,r; AL <br /> (COMPLETE IN TRIPLICATE)�f SC,4s .-.': H (,�- t <br /> Application is hereby made to the San Joaquin Local Health District for'a permit to construct and/or install th&j $z*L l��einQ1s$Ti his application is <br /> made in compliance with San Joaquin County Ordinance NP.1862 and the rules an-dregulat,o f the San Joaquin Local Health District. <br /> /Town 4 sS..-'6?0-01 <br /> Exact Site Address I <br /> Owner's Name Phone <br /> Address City— ` ---- <br /> /� # . Business Phone <br /> License <br /> Contractor's Name _ �+p !' "r�� / <br /> Contractor's Address { Emergency Phone T <br /> Is Certificate of Workman's Compensation ID? Yes P__ No <br /> nsurance on File With SJLH <br /> TYPE OF WORK (CHECK): NEW WELL El DEEPEN ❑ PRECONDITION❑ DESTRUCTION❑ J a <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ r <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit p 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 /> uG DOMESTIC/PRIVATE 11 DRILLED Dia. of Well Casing <br /> /K 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 a <br /> ❑ GEOPHYSICAL rface.Sea4 Installed By: <br /> PUMP INSTALLATION: Contractor <br /> l Type of Pump H'P <br /> PUMP REPLACEMENT: ❑ State Work Dane <br /> PUMP REPAIR: R State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby certify that 1 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 /> ?' <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> r 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 /> t. <br /> I II r a Grout pection prior grouting and a final inspection. /6V i <br /> Signed X Title: Date: f <br /> a (Draw PI an on ReversAide) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I • Date <br /> Application Accepted By <br /> Additional Comments: <br /> Phase 11 Grout Inspection P se 111 Final Inspection <br /> Inspection By }I1 Date Inspection By Qate <br /> Fee Is Due: C1 ANNUALLY El PER UNIT' El PER SITE ❑ EACH El January 1 &Received By January 31 �❑ JUIy 1 &Received By July 31 <br /> REMRASE EXPLANAT40N BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE o <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> '1 <br /> OTHER <br /> l a � � <br /> Received by. Date Receipt No. 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 <br />