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Appucanons vein tierrocessea vvnen suomntea rropenycompietea.tie sureTosignTheApplication. <br /> R OFFICE USE: APPLICATION <br /> . " -(for Non-Transferable,-Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT!- <br /> (COMPLETE IN TRIPLICATE) .WATER'>QUAl'ITY ` <br /> Application is hereby made to the San Joaquin Local Health District fora;permittoconstruct and/or instal Ithe work herein described.This application is <br /> made in compliance with++,lSan Joaquin Count Ordinance No. 1/86nd the'-•rules and regulations of the San Joaquin Local Health iJistrict. <br /> Exact Site Address pL 3 [7Y`CL C City/Town Q' <br /> Owner's Name AtLelf Clrf GbZ_ 4 0 d{�j// Phone 81 <br /> Address _ 1 City <br /> Contractor's Name i.-' �^o License# p��3 Business Phone <br /> Contractor's Address Emergency Phone <br /> 5 Is Certificate of Workman:sNrCampensation Insurance on File With SJLHD?r',-°1-Yes No <br /> "'TY•PEiOF WORK (CHECK): ' :'".NEW.WELL NC --DEEPEN ❑ RECONDITION❑' , :DESTRUCTION❑ <br /> WECC_CHLORINATION ❑ V4ELCS,ABANDONMENT ❑ OTHER ❑ PUMP INSTAL"LATION"❑ PUMP REPAIR-11 <br /> REPLACEMENT❑ -1 <br /> -:DtSTANCE TO NEAREST: Septic Tank f3 Sewer Lines Pit�':Privy-- <br /> Sewage Disposal Field Cesspool/Seepage Pit ,:: Other <br /> Property.Line .. .Pravate%Xdniestic',Well „Public Domestic'Well,•.. <br /> INTENDED-USE .TYPE,DFM- ELL = �j <br /> ❑ INDUSTRIAL <br /> -0 CABLE TOOL t7ia.:of:Wel! Excavation <br /> NeDOMESTIC/PRIVATE:' ..: 'DRILLED Dia. of Well Casing alfC _ <br /> ❑ DOMESTIC/PUBLIC - ••w ❑ DRIVEN Gauge of Casing } <br /> ❑ IRRIGATIONC -GRAVEL PACK Depth of.Grout Seal <br /> ❑ CATHODIC PROTECTION C 'ROTARY Type of`Grout c <br /> El-DISPOSAL ❑ OTHER `:Other Information U <br /> ❑ GEOPHYSICAL ¢ Surface Seal Installed By_ Pr <br /> :.PUMP INSTALLATION:r__ Contractor <br /> iType of Pump 1 t-P__ <br /> PUMP REPLACEMENTc.-,:.,,• ❑.State Work Done <br /> PUMP REPAIR: 0-State Work Done = <br /> DESTRUCTION OF WELL: >a'-17VeIl Diameter Approximate Depth <br /> ,Describe Material and Procedure, <br /> [-hereby,'certify that l 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 /> Home owner or licensed agent's signature certifles1h24ollowing:"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:-1 itl:the performance.of the work for which this <br /> permit is issued,.l shall employ persons subject to workman's compensation iawamf`California." <br /> I <br /> will call for <br /> a/JGrout Insp ctiah:prior to grouting and a final inspe�ctition. 1 <br /> Signed X !f 1_ Title: ��102 [L� .f 7 <br /> TDate: . +" L T 7 — <br /> .(Draw Plot Plan on Reverse Side) <br /> 1 FOR EPARTME T USE ONLY <br /> -PHASE-I <br /> r <br /> Application-.Accepted By Date_ 7 / /?/ <br /> Additional-Comments: <br /> } <br /> PIt se.tl:Grout.lns/p�ecttion Phase.11l Final Inspection—. <br /> Inspection i3y '�^'�` °*s�✓- E7'aTA 7- A3 ?i Inspection By � ate <br /> 4 <br /> 'Fee Is Due:-.0 ANNUALLY '❑ PER UNIT _ ❑ PER SITE ❑ EACH ❑>,Ianaary.1 &Received By January 31-- ❑ July S &Received By July 31 <br /> =-BI LING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT-DUE -CHECKED <br /> i. DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS { <br /> PENALTY <br /> OTHER <br /> OTHER [[[ <br /> Received by Date Receipt No. 'Permit No. - Issuance Date Mailed Delivered <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.HATELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />