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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOF OFFICE USE: ` APPLICATION �ee7 / <br /> (For Non-Transferable,Revocable,Suspendable) MP , LL � �✓ <br /> T ENVIRONMENTAL HEALTH PERMIT <br /> NPLETE IN TRIPLICATE) WATER QUALITY 440 <br /> Leication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work cram describetl.This application is <br /> made In compliance with San Joaquin County Ordin��",Ce N4 7862 and the rules a ynd r gulations of the San Joaquin�ogdi Wealth District. <br /> Exact Site address /� f? = S J�LX Tia o �lfi City/Town G�'I�1Iy. <br /> Owner's Name IF�e-II t /KR pdtN Phone <br /> Address — 11.%A t/"�I •C t"j� <br /> A�` City <br /> DantraCtar's Nemo '�`� ! /ri.v�T.J License If BUSInB35 Phoney 7�► <br /> Contractols Address 1D3. 41�,.t �/ ergency Phone -n <br /> Is Certificate of Workman's Compensation Insurance on File With SJL 4 YesNo W <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN E3RECONDITION�STRUCTION❑ <br /> WELL CHLORINATION❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION L9 PUMP REPAIR Q9 <br /> REPLACEMENT❑ � t <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy W <br /> Sewage Disposal Field Cesspool/Seepage Pit 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 /> p 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 /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL r Surface Seal In led By: <br /> PUMP INSTALLATION: Contractor LA <br /> .Type of Pump -tae /d H.P. <br /> / <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done T(�� S d a <br /> *RUCTION OF WELL: Well Diameter / VV V 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 00 <br /> (n <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 certifythat in the performance of the work for which this permit U <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 fallowing: 'I certify that in the performance of the work forwhichthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspi pr r ti�aaal inspection. <br /> Signed kIs: j�Io,P Date: <br /> (Dron Reverse Side) Jr <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By `fitly� �A.. Date <br /> Additional Comments:—� <br /> Phase 11 Grout Inspection Phaa III Final Inspection <br /> Inspection By IX\J IN Date Inspection By� Date <br /> Foe Is DYi:0 ANNUALLY ❑ PER 11Ntt ❑ PER SITE ❑ EACH ❑ January 1 S Rece,va ey January M ❑ July I a Reeeiv By July 31 <br /> BILLING REMITTANCE s REMIT <br /> BASE EXPLANATION DATE DATE RE ITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> l3I�S � �a8IB1 <br /> Recenea Dy Dete Rce <br /> aipt Na. Permit No. Issua— — Mailed Dellvareo <br /> APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMIT/SERVICES IWI E.HAZELTON AVE.,P.O.Boz 20911 STOCKTON.CA 95hn <br />