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f Applications Will Be Processed When Submitted Properly Completed. Be i To SignThe`A°pplicaArlim- � <br /> FOR OFFICE USE; APPLICATION JULUV(For Non-Transferable, Revocable, Suspendable) U28/9qii <br /> ENVIRONMENTAL HEALTH PERMIISAN j�.Y���� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HLALTH DIS--Q)�r+ '� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein cieWr7bed.This application is <br /> made in compliance wit San Joaquin.Countty Or Ina ce N . 1862 an the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address ?1� + �11 _ Q City/Town <br /> Owner's Name l Phone <br /> Address ? City <br /> Contractor's Name License# / usi ss Phone j .. <br /> Contractor's Address � '� _4 i!.,)_ 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❑ <br /> WELL CHLORINATI ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other _ r, <br /> Property Line 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 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 4) <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> UMP REPLACEMEN - ❑ State Work Done <br /> PUMP ❑ State Work Done <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:1 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." <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 s bject to orkman's compensation laws of California." ^' <br /> I w' If for a Grout Inspe prior routi and a final inspection. <br /> Signed X 6 Title: Date: <br /> (Draw Plot Plan on Reverse Side) 1 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted B "-v`—r Date <br /> Additional Comments: a <br /> Phase II Grout Inspection se III final Inspection <br /> Inspection By 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 /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE . 0 <br /> `I <br /> LESS <br /> PRORATION <br /> I <br /> PLUS <br /> I <br /> PENALTY <br /> OTHER <br />` OTHER J <br /> J a�1,9 -7 <br /> Received by Date - - Receipt No. Permit No. Issuancti Datel Mailed Delivered �y <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.,HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 06201 +.:/ <br />