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TheApprimamon.Applications Will Be Processed When Submitted Properly Completed, BeSureToSign <br /> F RAN-., ICE USE: <br /> APPLICATION r m�-1 gv� os <br /> (For Non-Transferable,Revocable,,Suspendable) ��&WELL <br /> ENVIRONMENTAL HEALTH PERMIT �y l <br /> (COMPLETE IN TRIPLICATE) 1. 7Z- 'v f� WATER QUALITY v�ar fAcgy�' �,¢ `�,, �w <br /> Application is hereby made to the San Joaquin Local Health Districtfor a permit to construct and/or install the work herein described.Tfiis application is <br /> made in compliance_with San J in County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> City/Town 4 111 le <br /> Exact Site Address p� <br /> �. Phone <br /> Owner's'Name h s <br /> City <br /> Address <br /> License# /=3z. Usiness Phone <br /> Contractor's NameI1/ <br /> Contractor's Address ��/3^ 9 S Emergency Phone <br /> Is Certificate of Workman's Compensation Ilnns�urance on File With SJLHD? Yes�� No <br /> DESTRUCTI NO <br /> TYPE OF WORK TION 0 WE W ABANDONMENT ❑-_ DEEPEN ❑ OTHER RECONDITION❑P INSTAL ATIOty PUMP REPAIR❑ <br /> WELL CHLORINATION , <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines_� Pit Privy I <br /> Sewage Disposal Field Cesspool/Seepage Pit Other Q <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL `g!/ <br /> INDUSTRIAL �A ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 11 DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> ❑ IRRIGATION 12 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION M ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor H P c <br /> Type of Pump Ma <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP RE ❑ <br /> State Work Done PAIR. S Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <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 for which this permit i <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." ; <br /> cting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> Contractor's hiring or sub-contra <br /> I 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 /> -.Date: <br /> Signed X <br /> Title. <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I 1 Date <br /> - Application Accepted By <br /> Additional Comments: t., <br /> ` rph a II Grout Inspection t <br /> �pa III Final Inspection T } <br /> Inspection By <br /> [� ate �- Inspection By Date <br /> i <br /> Y ❑ PER UNIT ❑ PER SkTE ❑ EACH <br /> Fee IS Due., [I ANNUALLY ❑ January t &Received By January 31 ❑ July} &Receiv REMITd By uIy 31 <br /> 'BILLING REMITTANCE $ 'AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE T! <br /> LESS <br /> PRORATION _ <br /> PLUS s <br /> PENALTY, + ' <br /> OTHER <br /> OTHER <br /> y 3oq.q3 � r <br /> Receive by -' <br /> Dald Receipt No. Permit No —- I uance Date Mailed - Delivered <br /> 5201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1501 E.HAZELTON AVE.,P.O.Box 2009 STOCNTON,CA 9 <br />