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Applications Will Be Processed WhenSubmitted ProperlyCompleted. Be 5qM&Sign TneApplication <br /> FOR OFFICErUSt-_ APPLICATION APR 9 1980 0� <br /> (For Non-Transferable, Revocable, Suspendable) j !yl <br /> LVELL <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQUI19U iOA <br /> HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and a ules and regulations of the San Joaquin 4ocal Health District. <br /> Exact Site Address 17 <br /> / -� + City/Town / <br /> Owner's Name �L Phone 3� <br /> Address Ctty -D'� r��^-���A cis <br /> Contractor's Name License# Business Phone_ � 1-2� r <br /> Contractor's Address4 Emergency Phon/e� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes N�i No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLAGEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well gio/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 a' <br /> ❑ GEOPHYSICAL Surface Seal Installed By: W <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure E <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 /> Homeowner 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." <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 /> I all fo a Grout I ecti n prior to grouting and a final inspe n. <br /> Signed X Title: n Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FORD PARTMENT USE ONLY <br /> PHASE I Xv/s <br /> � <br /> Application Accepted By a Date <br /> Additional Comments: <br /> Phase II Grout Inspection aFinal Inspection <br /> Inspection By Date Inspection ' Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNITPER S1TE ❑ EACH E] January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE t <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />