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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign T Lk fps, f j J ) <br /> FOR OFFICE USE: ; ' APPLICATION �a f ( <br /> (For Non-Transferable, Revocable, Suspendable) t,P 1981 <br /> ENVIRONMENTAL HEALTH PERMIT / <br /> WATER QUALITY E . o , SA �tF?^.tom!;jjV` LOCAL V <br /> (COMPLETE IN TRIPLICATE) h7 i phi ' D <br /> Application is hereby madetothe San Joaquin Local Health Districtfora permit to construct and/or install the work hereiAJ4 t_" s>�. �I "- n is <br /> made in compliance with San Joaquin County.Ordiria9ce No. 1862 and the rules and regulations of the San Joaquin Local Healthplstn/c�t..� <br /> Exact Site Address City/Town � f , ! Z <br /> Owner's Name Phone �? c. <br /> Address City 't <br /> Contractor's Name License# iness Phone <br /> Contractor's Address - Emergency Phone 4 <br /> Is Certificate of Workman's ompensation Insurance on File With SJLHD? Yes No 1 <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION[] <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ `} t <br /> REPLACEMENT❑ 01 <br /> DISTANCE TO NEAREST: Septic Tank Y Sewer Lines Pit Privy <br /> Sewage Disposal:Fieid Cesspool/Seepage Pit Other - <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 01-INpJJSTRIAL ❑ CABLE TOOL Dia. Of Well Excavation <br /> OMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> El IRRIGATION E] GRAVEL PACK Depth of Grout Seal- <br /> 0 CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> z <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL_ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor L <br /> t _ "..�+ w"� H.P. <br /> Type.o P 51 <br /> PUMP REPLACEMENT: tate Work Done_ C? <br /> 'f V <br /> ❑ State Work Done r' <br /> PUMP REPAIR: _ _ G <br /> DESTRUCTION OF WELL: Weil Diameter ;'Approximate Depth <br /> Describe Material and Procedure t I <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 laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I 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 /> for a Grout lnspe prior to uting an final inspection. <br /> Signed X f Title: -_ Date: - •� <br /> (Draw lot Plan on Reverse Side),,, ! <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Date 1 _1 t <br /> Application Accepted <br /> By` <br /> -� <br /> Additional Comments: <br /> Phase II Grout Inspection -P !� <br /> ha lit Final Inspection <br />€ Inspection By�� Date Inspection By D�e <br /> Fee IS Due: 13 ANNUALLY ❑ PER UNST ❑ PER SITE 11EACH ElJanuary 1 &Received By January 31 ❑ July 1 &Received By July 31 ; <br /> REMIT <br /> BILLING REMITTANCE. $ AMOUNT DUE CHECKED- <br /> BASE EXPLANATION DATE DATE REMITTED ( AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> _ Y <br /> PLUS <br /> PENALTY - - <br /> OTHER <br />�4 OTHER 'r• - <br /> Received by - Date - -Receipt No. -- Permit No. Issuance to Mailed-. Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 , <br />