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Applications Will Be Processed When Submitted Properly Completed. Be Sure To , <br /> g�( �aAgl�li io <br /> iFOR oFt Ice use: APPLICATION pct l; �.� t <br /> � 71-1`41 (For Non-Transferable, Revocable,Suspendable <br /> I <br /> ENVIRONMENTAL HEALTH PERMIT MAY 2PMT&WELL' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY t ft CAL <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thSANkd&AQeC }�Vapplication is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sas#oAJu i�oM health District. <br /> Exact Site Address1,Z S City/Town _ dd <br /> Owner's Name X [/ � � X Phone , D <br /> Address City /A,,- dl <br /> Contractor's Name 01/5 W,L e Al"A'A�Q License#2�`.?3'�f Business Phone Z3'3^.qY6r 0 <br /> Contractor's Address _&zw 5,f)""P 102M Cxxjf Emergency Phone -5 A I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Noy <br /> CHECK : NEW WELL <br /> TYPE OF WORK g� i <br /> (CHECK): I� DEEPEN ❑ RECONDITION❑ DESTRUCTIO ❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION K PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1 Sewer Lines Pit Privy V' - <br /> Sewage Disposal Field Cesspool/Seepage Pit 13a Other w <br /> Property Line Private Domestic Well end/_.... Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL CABLE TOOL Dia. of Well Excavation it <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 2- Q <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ®jNt <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Inst Iled By d <br /> PUMP INSTALLATION: Contractor W � � (� <br /> Type of Pump—51" CW,;J 1i �@ 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 hAe 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 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:"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 will call for a Grout Inspection prior to grouting and a final inspection. <br />_ Signed X ✓,t��� � Title: Dafe: $—/ / <br /> (Draw Plot Plan on Reverse Side) <br /> F. <br /> PHASE I <br /> FOR DEPARTMENT USE ONLY <br /> �D`n��[,�� <br /> Application Accepted SyaN2N, Da <br /> Additional Comments: <br /> . i <br /> a II Grout Inspection 1 Phase I inal Inspection I <br /> Inspection By Date Inspection By r Date "N2- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLfNG REMITTANCE $ <br /> DATE DATE REMITTED AMOUNT DUE CHECKEDAMOUNT <br /> FEE <br /> LESS O <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 4 <br /> OTHER , <br /> 8 la-h } (:��3 16 13 S5 <br /> Recei'ed by Date -Receipt No. Permit No, Issuance Date MaiiIed Delivered - <br /> APF LICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo j 2009 STOCKTON,CA 95 1 <br />