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ApplicationsWill Be ProcessedWhen Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable,'Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUNII�.�&WELL j <br /> Z <br /> � i <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY . <br /> Application is hereby madeto theSan Joaquin Local Health Oistrictfora permittoconstructand/orinstallthework herein described.This application is. <br /> made in compliance w" a Jq dinance No. 1862 and t e rules and regulations of the San J aqu Local l�Health_District. - - <br /> Exact Site Address oaCity/Town _ Q t p ! �. <br /> Owner's Name • Phone <br /> Address City o C p a <br /> Contractor's Name 14,11 iL icensd36 0.7 Business Phone <br /> Contractor's Address Emergency Phone — <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ,[l No <br /> TYPE OF WORK (CHECK): NEW WELL E!�-' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ Qs <br /> REPLACEMENT❑ l �( <br /> DISTANCE TO NEAREST: Septic Tank � 17 Sever Lines C� -�" Pit-Privy <br /> Sewage Disposal Fi d �"�L Cesspool/Seepage Pit /( C LQ. 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 /> UT OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing z <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Se I� <br /> ❑ CATHODIC PROTECTION 2P—ROTARY Type of Grout - <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor a <br /> Type of Pump H 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 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 certifies the following:"I certify that in the performance of the work forwhich this permit <br /> --is-issued-,4-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 call for a ro p do prior to groutin�and final inspection. <br /> Signed Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> - w <br /> FOR DEPARTMENT USE ONLY <br /> PHA <br /> Application Accepted By Z Date <br /> Additional Comments: :5 <br /> Phase II Grout Inspection P ase III Final Inspection' <br /> Inspection By '� _ Date—Z0--Z-2 W--7-.9 <br /> Inspection By DateO <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT $rPER SITE ,..❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUEJ CHECKED <br /> �f- DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS _ 441 <br /> _ +yl� <br /> PRORATION M <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER }} <br /> 1 <br /> Received by " Date Receipt o. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ,ENVIRONMENTAL HEALTH PERMITISERvicES 1801 E.HAZELTON AYE.,P.O.Box 2p09 �STOCKTON,CA 95201 <br />