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Applications Will Be Processed When <br /> Submitted Properly Completed.Be S o h c IoUU <br /> FOR OFFICE USE. APPLICATION � r <br /> {For Non-Transferable, Revocable, Suspendable} J U� LHVIP �LL <br /> ENVIRONMENTAL HEALTH PERMIT ,AN jOAQUIN I O"-AAL <br /> {COMPLETE IN TRIPLICATE} <br /> WATER QUALITY HEALTH. ©ISTR1�� <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.hereln escnbe his application Is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and th rules and regulations of the Sand L A-44ocaJHealth District. <br /> �, ,� City/Town �c74 Y <br /> Exact Site Address �� <br /> a: s. Phone c <br /> Owner's NameCit <br /> Address C I 05 L `7L. i1 - y - 0 <br /> ;. {)f License# ' d. Business Phone <br /> Contractor's Name ' Emer ene Phone <br /> Contractor's Address /rte' E Emergency <br /> No j <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 1 ' DE / - <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION C1WELL ABANDONMENT ❑ OTHER C3PUMP INSTALLATION 11 PUMP REPAIR j <br /> REPLACEMENT+IO I <br /> Sewer Lines Pit Privy �. <br /> DISTANCE TO NEAREST: Septic Tank e Cess ool/Sea e Pit +� � Other <br /> Sewage Disposal Field p p g aQ <br /> Property.Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL pia. 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 /> ❑ ROTARY Type of Grout _C <br /> E] CATHODIC PROTECTION <br /> 13 DISPOSAL El OTHER Other Information w <br /> % <br /> ❑ GEOPHYSICAL Surface Seal Installed By: v <br /> PUMP INSTALLATION: Contractor <br /> H.P. <br /> Type of Pump <br /> PUMP REPLACEMENT: --State Work Done <br /> Done <br /> PUMP REPAIR: ❑ State Work <br /> DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth -v <br /> Describe Material and Procedure <br /> 4 <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. •A I - <br /> Homeowner or licensed agent's signature certifies the following-."I certify khat 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 /> 1 'I all for a Gro s ion prior 10 grouting and a final inspectt <br /> Title: Dale' �' � <br /> Signed X <br /> i (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY p ` <br /> PHASE I �f~7 Date <br /> Application Accepted By' <br /> Pp , <br /> Additional Comments: <br /> Plias II Final Inspection <br /> 4 Phase II Grout Inspection Date <br /> Inspection By Date Inspection <br /> ❑ UNIT ❑ PER SITE El EACH ❑ January 1 eceived By January 31 ❑ July t 8 ReceiveRdBy EMiTuly 31 <br /> Fee is Due: ❑ ANNUALLY PER <br /> BILLING. .REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> � FEE <br /> LO <br /> LESS <br /> PRORATION ; <br /> PLUS <br /> PENALTY <br /> E OTHER <br /> OTHER <br /> Received by - Date - Receipt No. <br /> Permit No Issuance Date Mailed Delivered <br /> N AVE.,P.Q.60■2609 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1501 E.HAZELTQ <br />