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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sig Dt Apt�licatia 190 <br /> FOR OFFICE USE: APPLICATION. t ft 190 <br /> -� (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SAID ygM�&IWiI:LOCAL <br /> _ HEALTH DISTRICT <br /> (COMPLETE IN TRIPLICATE) L7tF(� , /�Cn4�G-r�d$ ATER QUALITY �� . 7- �3 <br /> k Application is hereby made to the San Joaquin Local Health District fore.permitto construct and/or install the work herein described.This application is <br /> made in compliance with San <br /> _Jo[aquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address�5_ /✓ City/Town �7 �p�0�+/ <br /> ®® .217/ 1� <br /> Owner's Name Phone—Rr `� <br /> Address City -41 6 v <br /> Contractor's Name ,. JLJ lv License#c27!?D/O Business Phone��� � <br /> Contractor's Address ao 33 XIIvEmergency Ph— n <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes A1" No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER © PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT"❑ <br /> DISTANCE TO NEAREST: Septic Tank; Sewer.Lines.a. . 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 <br /> ❑ DOMESTIC/P BLIC ❑ DRIVEN Gauge of Casing <br /> W IRRIGATION(IG) © GRAVEL. PACK Depth of Grout Seal <br /> t 0 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: 99 State Work Done V!R 021a _Q <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> } <br /> I hereby certify that I have prepared this application and that the work will be done .in accordance with San Joaquin County t <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 /> i 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 c r a Grout Inspe �n prio to grouting and-a final inspect' `5 <br /> r Signed X Title: -L_J Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE Iq�� Q s� <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout inspection se 111 Final Inspection <br /> Inspection ByM InDate Inspection By,C� Date" <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑.PER SITE ❑ EACH ❑'January 1-&Rec(�eiv/e/d By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> pp AMOUNT ' <br /> FEE. <br /> LESS <br /> I <br /> PRORATION <br /> [t 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 />