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A hcations Will Be Processed When Submitted Prp erl Completed. Be S Sign The Application. <br /> t1 vFFICE U5� APPLICATION 'o Tn q looQ <br /> (For Non-Transferable, Revocable, Suspendable) APR 10 o 1 <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAOU!��um 1vELL J <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT <br /> Application is hereby madeto 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 N ,1862 and the rules and regulations of the San Joaquin Local Health <br /> Exact Site Address Firs Christian ChurC�i 1125 N. union Rd. MantecCa <br /> City/Town a, <br /> Owner's Name First Christian Church $2ant Manteca, <br /> t Address 1125 N• n�on Phone <br /> A.Contractor's Name Ae <br /> City Manteca, a <br /> c r1 <br /> fa �License# 2560$6 Business Phone 2 <br /> Contractor's Address mergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File Yes � No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ SA <br /> WELL CHLORINATION ❑ 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 <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 i <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: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done . <br /> PUMP REPAIR: Q State Work Done <br /> DESTRUCTION OF WELL- Well Diameter C <br /> Approximate Depth 5 <br /> Describe Material and Procedure <br /> n <br /> I hereby certify that I have prepared this application and that the work will be dome in accordance with San Joaquin County S <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, erson in such manner as to become subject to workman's compensation laws of California." f <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify thatin the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation lavvs'of California." ' <br /> I will all for a Grout I tion prior to grouting and a final inspection. <br /> Signed X Title: <br /> (Draw Plot Plan on Rev se Side) Date: i <br /> t <br /> F R DEPARTMENT USE ONLY <br /> PHASE [ <br /> Application Accepted 13y �© <br /> Additional Comments: <br /> Date <br /> Phase 11 Grout Inspectio Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31. <br /> R t <br /> - BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> " I DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS - <br /> PRORATION ? <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> om <br /> Received by Date _ Receipt No. Permit No. Issuance Date <br /> Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> _ 1601 E.RAZELTON AVE.,P:O.Box 2009 <br /> STOCK ON,CA 952 <br />