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y. --..rrYcra�- <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignTheApplicaiion. <br /> [FOR oFF�cE USE: APPLICATION , <br /> (For Non-Transferable, Revocable, Suspendable) Pl1MP&�y/ELL �" <br /> .E ENVIRONMENTAL HEALTH PERMIT .� <br /> x WATER QUALITY <br /> (COMPLETEN TRIPLICATE) tree-43 w _�'' S / <br /> Application is hereby made tothe`San Joaquin Local Health Districtfora permitto construct and/or install thework.herein described.This applic&ion is <br /> made in compliance with San Joaquin Count Ordiingnce No. 1862 and the rules nd regulations of the S n Joaquin Local Heath District. <br /> Exact Site Address "' it o <br /> Owner's Name Phone — ; <br /> City <br /> Address <br /> Contractor's Namer License# 9�� Business Phone <br /> Contractor's Address t Emergency Phone �� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? YesX � No <br /> TYPE OF WORK (CHECK): NEW WELLD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> 1210 <br /> WELL CHLORINATION El WELL ABANDONMENT ❑ OTHER IDPUMP INSTALLATION❑ PUMP REPAIR C3 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy i <br /> Sewage Disposal Field 0�74' Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL / 0 <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 /> 11 DISPOSAL <br /> El OTHER Other Information 4 <br /> i <br /> 13 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H. <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 /> r Contractor's hiring or sub-contracting signature certifies the following:"l certify that in the performance of the work for which this <br /> f permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> f <br /> I will c II for a Grout Inspec ion prior to grouting and a final inspection. <br /> Title: Date: <br /> Signed X <br /> (Draw Plot Plan on Revers Side) a <br /> �j� FOR DEPARTMENT USE ONLY <br /> PHASE I .% Date <br /> Application Accepted By —� <br /> Additional Comments: <br /> P e roui_Inspection Phase III Final Inspection <br /> Inspection B r Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 E] July 1 &ReceivedREMIT 37 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> � 6 <br /> FEE l <br /> LESS t <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> �s <br /> OTHER <br /> OTHER <br /> yr Received y ate Receipt No, Permit No. issuance Date Mailed Delivered <br /> ` APPLI ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />