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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) 'PUAAP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Jo quin Loyal Health District. <br /> Exact Site Address 17 p�7 .. City/Town !�Cc(! <br /> Owner's Namein C-r -P t <br /> Phone <br /> Address City v <br /> Contractor's Name � z.tet. —1 License# 3 r <br /> ���1� Business Phone` <br /> Contractor's Address ,3(7Q 1_ 7Ui-_10'Cd Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ vV <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El 1 <br /> REPLACEMENT❑ f <br /> DISTANCE TO NEAREST: Septic Tank !(JU Sewer Lines rte" Pit Privy <br /> Sewage Disposal Field C/ e Cesspool/Seepage Pit Other <br /> Property Line r Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing (19 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 47 <br /> ❑ IRRIGATION POTHER <br /> RAVEL PACK Depth of Grout Seal <br /> 1:1 CATHODIC PROTECTION OTARY Type of Grout <br /> 11 DISPOSAL Other Information t% <br /> © GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done rr <br /> DESTRUCTION OF WELL: Well Diameter 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 <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 <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." p <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this r <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Ins ction prior to grouting and a final Inspection. <br /> Signed XTitle: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> Q FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By �� Date 14 '� <br /> Additional Comments: <br /> 410- <br /> ha� out Inspection Phase III Final Inspection <br /> inspection By I Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION $ AMOUNT DUE CHECKED <br /> FEE U 1 <br /> DATE DATE REMITTED <br /> AMOUNT <br /> � � O <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER { <br /> 4JS E; <br /> Received by Date Receipt No. Permit No. Iss nce Dat Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> J <br />