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Applications Will Be Processed When SUSKitted Properly Completed. Be Sure ToSignTheApp"Cauon a , <br /> "I r 0� <br /> r_ i (#` t <br /> FOR OFFICE USE: APPLIOATION <br /> For Non-Transferable, Revocable, Suspendable) 11P',MP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT DEC 291982 <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 hefeip described:;1}i ix,"ap1'u;` �i'�p is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin L-¢ca1=UiAtih jDijtY�;�iCT <br /> Exact Site Address 4 g P <br /> Q } 10/ <br /> City/Town . <br /> Owner's Name_ -,�. �' Phone <br /> Address36 City <br /> Contractor's Name License# !6.� a S <br /> B s Phone f` I <br /> Contractor's Address 16 Emergency Phor I N <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 6 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR S <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 /> ❑ OMESTIC/PRIVATE 13 DRILLED Dia. of Well Casing <br /> u 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: 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 /> 7 <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:"[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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X ea"" o", Title: Date: <br /> (Draw Plot Plan on Reverse Sid ) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEt <br /> Application Accepted By Date 1� '�"��� <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Fina nspection J <br /> Inspection By Date Inspection By V Date I f <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEES <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> kir <i <br /> Received by D to Receip4 No, Permit No, Issua ce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1001 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />