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FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendabl�e'-) l <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) -WATER QUALITY <br /> Application is hereby made to the SanJoaquin Local Health D.istrictfor:apermit to construct and/or install the work herein described.This application is <br /> made in compfiance with Spann Joaquin County"Ordinan w.hlar,.7862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address "' i 0 V►1. 61V Cit /Town Tr <br />[ Owner's Name i r C Z _ <br /> Address j �1rC�'l .;Pfrp,ne __����'�-�v`7�" <br /> —,City .Tfi's3Cy <br /> Contractor's Name I cense# I - ��usiness Phone �Fj4-15 <br /> Contractor's Address ;]ar Oda if M06 Ca5tn Emergency Phone !gam <br /> Is Certificate of Workmaris Cbmpensation Insurance on File With,,SJLHD? Yes No . <br /> TYPE'.OF WORK (CHECK): NEW WELL©' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION © -,;.WELL ABANDONMENT 0 OTHER ❑ 'PUMP INSTALLATION © PUMP-REPAIR❑ <br /> :REPLACEMENT❑ <br /> :'DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 'Sewage Disposal Field I - Cesspool/Seepage Pit Other <br /> v: Prgperty'Li ne' Pxivat6.,Domestic'Well Public Domestic Well <br /> INTENDED USE ":. TYPE OF WELL .r <br /> ❑ INDUSTRIAL-.- ❑ CABLE TOOL Dia.-of Well Excavation,,—' <br /> 19-DOMESTIC/PRIVATE 0--DRILLED •'Dia..of Well Casing & <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 6L <br /> ❑.IRRIGATION 'GRAVEL PACK Depth of Grout Seal X61 <br /> 0:CATHODIC PROTECTION ROTARY Type of Grout �C _ �''Zl`olnhIt� C <br /> IJ DISPOSAL . . 11 OTHER Other Informationy� IAV 616=r- <br /> 0 <br /> 16=r❑ GEOPHYSICAL Surface Seal Installed By:. <br /> PUMP INSTALLATION:. ContractorJ C' <br /> Type of Pump H.P. S <br /> PUMP REPLACEMENT:,;;. ❑ state Work Done_. 7V <br /> PUMP REPAIR: ❑ State Work Done Y <br /> DESTRUCTION OF WELL . WeILDiameter Approximate.Depth. <br /> Describe Mate ' and Procedure <br /> r . <br /> hereby certify�tfrat 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 oltowing:"I certify that in the performanceof-the work forwhich this permit <br /> is issued, I shall not employ any person in such manner as to.become subject to workman's compensation laws of.Cal itornia." cs <br /> Contractor's hiringor sub-contraciin signature certifies the following:g 4 g:".l�ertffy that in the performance of the work.forwhich this -- <br /> permit is issued,.lrslxall-=employ,persons."subject to workman's compensation laws of California." <br /> I will call for&• 3rbut Inspection priiortolWouting and a final inspection. <br /> Signed X V2202U L i �WJL2 Title: — l JC k� . Date: r] _ 2.4..'1cq <br /> ..(Draw Plot Plan on Reverse Side) <br /> * FOR DEPAR MENT USE ONLY <br /> PHASE-1 w <br /> Application Accepted By -Oate �Sr '7 <br /> .Additional Comments: <br /> Phase 11 gout inspection Phase III Final Inspection <br /> ..:.Inspection By Date Inspection By Date �-' 7 <br /> Fee-Is-Due: ❑ ANNUALLY; :e:' ❑ PER UNI ❑ PER SITE ❑ EA H ❑ January 1 &Received By January 31 July 1 &Received By July 3 <br /> REMIT <br /> BILLING REMITTANCE $. <br /> BASE EXPLANATION DA�r DATE REMITTED �.'MOUNT_DUE CHECKED <br /> . AMOUNT <br /> FEE <br /> LESS dd <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER nn <br /> V <br /> Recewed by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Hoc 2009 STOCKTON•CA 95201 <br />