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. . r •v ..•••N.c.c.a. vc -w ou a19" IneApplication. <br /> FOR OFFICE USE: APPLICATION <br /> Vor Non-Transferable,aRevocable„$ospendabie) <br /> a_••. 7 y 33 <br /> - .fhIV1RONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) j 'Cf 40 „ P ra_� , _ yTER UAtITY SSS— 03—i'S <br /> Application is hereby made to the San Joaquin Local Health Districtfort plrmltto construct and/or install the work herein described,This application is <br /> < •made in compliance with San Joaquin Countyrdinance No. 1862 and the rules and regulations of the San Joaquin/,ocaf Friealth blatrict. <br /> Exact Site Address N &&4Lop, <br /> City/Town �r7 4 , <br /> Owner's Name r e6S J6�pr� Phone 6g <br /> Address =-=._L 1Al-r, /� City Dc c, <br /> Contractor's Name License# `; �3 BusinessiPh6rie <br /> Contractor's Address _f'"A 1-moi t� iat/�C�Y! �- <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? -Yes - No -�- <br /> TYPE OF WORK (CHECK); :NEW WELL 0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION&___ PUMP REPAIR© <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank /7,C_ Sewer Lines Pit Privy <br /> Sewage.Disposaffield Cesspool/Seepage Pit _'Other_ <br /> Property Line Private-Domestic Well Public Domestic Well <br /> INTENDED`'IJSE TYPE OF WELL <br /> •.O INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> O DOMESTIC/PRIVATE ❑-DRILLED. r Dia_,,of Well Casing <br /> DOMESTIC/PUBLIC 0 DRIVEN Gaugenf-Casing 16t) V�- <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth.of Grout Seal <br /> ❑ CATHODIC PROTECTION �OTARY Type of Grout.—_ 01_1 +- <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ?. Surface Seal installed By: e p <br /> PUMP INSTALLATION: Contractor - <br /> Type of Pump dtt&hH.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 Jimquin County .- <br /> ordinances, state laws, and rules and regulatiOns of the San Joaquin Local Health District. <br /> }come owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for+riNc:h.thiapermit <br /> is issued, i shall not employ any person in such manner as to become subject to workman's compensation lavomf 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,nrifl call or a.G� ut'I ction prior to grouting and a final inspection. -7-- <br /> � A (� <br /> Signed X Title: a6 ^ Dale: / ( _f <br /> (Draw Plot Plan on Reverse Side) <br /> FOR D PARTME T USE ONLY <br /> -PHASE f <br /> Application Accepted By <br /> _ Datu <br /> Additional Comments_ 10• <br /> Phase II Grout Inspection Phase III Final Inspection p �+ <br /> Inspection By ��� Inspection By Date ? <br /> Fee Is Due: ❑ ANNUALLY-”, E3 PER UNIT ❑ PER SITE " ❑ EACH ❑ January 1 &Received By January,91 /':'-❑ July 1 R Received By July 31 <br /> BILLING REMITTANCE y REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED ' <br /> DATE DATE REMr3rE0 AMOUNT <br /> FEE <br /> LESS 7 D <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -7 q <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.Boa 2009 STOCKTON,CA 95201 <br />