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a Applications Will se Processed When Submitted Property omp 4 <br /> I <br /> APPLICATION <br /> „E USE: <br /> #, t (For Non-Transferable, Revocable, Suspendable) 4 PU P - L <br /> oe <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY Q(o -(L ,o- <br /> (COMPLETE IN TRIPLICATE) "(Q(L`1 C f{�G r4-..l L'U <br /> Application is hereby made to the San Joaquin Local lHealth lDi�{ric oar econstruct a <br /> e rttesandregulatdloonslofttheSan,J/oaq�ui'nlLocalcHeathDistapplicationis <br /> made In compliance with San Joaquin County �� City/Town _!^`��- <br /> Exact Site Address <br /> P Phone 44-1 <br /> Owner's Name City <br /> Address License �� Business Phone_ <br /> # � <br /> Contractor's Name Emergency Phone ' <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation Insuran a on File With SJ LH D? Yes DESTRUCTION t <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION r R <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER 13 PUMP INSTALLATION PUMP REPAIR❑ <br /> `J a <br /> REPLACEMENT❑ Sewer Lines pl +Aq Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE.,4F WELL <br /> ❑ INDUSTRIAL. ❑ CABLE TOOL Dia, of Well Excavation 1 <br /> 11 DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PRIVATE Gauge of Casing <br /> 13DOMESTIC/PUBLIC 13 DRIVEN- <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> fl5-1riRIGATION ❑ ROTARY Type of Grout <br /> t' ❑ CATHODIC PROTECTION Other Information <br /> I ❑ DISPOSAL ❑ OTHER <br /> Surface Seal Installed By: <br /> I ❑ GEOPHYSICAL <br /> Contractor U <br /> PUMP INSTALLATION: H.P. <br /> h Type of Pump <br /> PUMP REPLACEMENT: <br /> 11 State Work Done <br /> PUMP REPAIR: P State Work Done <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> r 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, 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:It 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 Gr t nspection prior to grouting and a final inspection. <br /> Date: <br /> Title:v f <br /> I Signed X <br /> r (Draw Plot Plan on Revers�Sde) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date �� <br /> Application Accepted B. <br /> Additional Comments: h 111 Final Inspection //-�� �� <br /> Phase 11 Grout Inspection Date V <br /> Inspection By <br /> Date inspection By <br /> 31 <br /> REMIT <br /> Fee 1s DUB: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> *'•BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> r <br /> s � <br /> FEE <br /> LESS <br /> I PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ( OTHER <br /> 3 <br /> ;. -� L4 3 <br /> � Delivered <br /> Received by Date Receipt No Permit No. Iss anc Date Mailed <br /> k <br /> 1601 E.HAZELTON AVE.,P.O:Box 2009 STOCKTON,.CA 45209 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />