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Ie`Leu. <br /> Applications Will Be Processed When Submitted rope TE <br /> �t t� 1980 <br /> APPLICATIONELL <br /> V <br /> FOR OFFICE'USE: (For Non Transferable, Revocable,Suspendabfe) n �Ikt <br /> S <br /> ENVIRONMENTAL HEALTH PERMIT $p,N K <br /> e - H �lJA <br /> WATER QUALITY HEhLT <br /> application is <br /> (COMPLETE 1N TRIPLICATE) <br /> A lication is hereby made to the San Joaquin Local Health Dist�gfi2 andp he roto construct uI tdions ofor tthe San Joaquinll the work l L2ocalHealdlh Dist.This t ; <br /> Pp <br /> made in compliance with °a County Ordinc� [ City/Town ` �_.- <br /> Exact Site Address / { {� 4 `'� " <br /> L Phone <br /> G <br /> `~/ 1' ! I[ City-- <br /> - <br /> Owner's Name � ,2 <br /> G City <br /> Address �ense# Business Phone <br /> Contractor's Name C Emergency Phone <br /> Contractor's Address NO <br /> e on File With <br /> Is Certificate of Workman's Compensation InsurancSRECONDITION❑ DESTRUCTION 13Q <br /> TYPE OF WORK (CHECK): NEW WELLDEEPEN <br /> WELL ABANDONMENT <br /> WELL CHLORINATION ❑ ❑ OTHER 13 PUMP INSTALLATION 13PUMP REPAIR <br /> ❑ <br /> REPLACEMENTPit Privy <br /> (�? Sewer Lines Other <br />` DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line TYPE OF WELL `(\l <br /> Private Domestic Well �!! <br /> I. <br /> INTENDED USE El CABLE TOOL . Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> M DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> 13 DOMESTIC/PUBLIC Depth of Grout Seal <br /> 13 GRAVEL PACK ..11 <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION 13 OTHER Other Information <br /> ❑ DISPOSAL rr S face Seal Installed By: <br /> ❑ GEOPHYSICAL i <br /> Contractor H.p. <br /> PUMP INSTALLATION: S <br /> T pe of Pump -per <br /> I <br /> ( � State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Well Diameter <br /> Describe Material and Procedure � <br /> lication and that the w°rk will be done in accordance with San Joaquin County <br /> #k l hereby certify that l have prepared this app 0 <br /> f ordinances, state laws, and rules and regulations of the San Joaquin Local Health District: � <br /> g:.. y <br /> I certch manner as to become subject to workman's compensation laws of California." <br /> Home owner or licensed agent's signaturen sutfies the foil owing: l certify that in the performance of the work for which this perm) <br /> I shall not employ any person <br /> is issued, fies I certifythat in the performance of the work forwhich this <br /> Contractor's hiring or sub-contracting gsubject to naturtworkman'sllaompensation laws of California." <br /> permit is issued, I shall employ p � and a final inspection. - <br /> I will t Inspection prior to grouting Date: - <br /> Title: <br /> Signed X (Draw Plot plan on Reverse Side) <br /> FO DEPA MENT USE ONLY <br /> ' Date d <br /> PHASE,I" <br /> E Application Accepted By <br /> Additional Comments: / Phase Ill Final Inspection <br /> Phase 11 Grout Inspection Date V <br /> ) Date Inspection By <br /> Inspection By <br /> ed By <br /> rk{ REMIT <br /> Fee IS Due; ❑ ANNUALLY PER UNIT WL PER SITE EACH ❑ January i &Received 8y January 31 ❑ July 1 &Rece�CHEGKEDJuly <br /> 3 <br /> REMITTANCE AMOUNT DUE <br /> BILLING DATE REMITTED AMOUNT <br /> BASE EXPLANATION DATE <br /> r <br /> k <br /> FEE <br /> LESS <br /> PRORATION - M <br /> PLUS <br /> PENALTY <br /> OTHER - f <br /> OTHER <br /> t o` -LssuancUe Date Mailed De4ivered <br /> --n, f- - Permit No. <br /> Date Receipt No. 1601 E.HgZELTON AVE.,P.O.Box.2009 <br /> STOCKTON,CA 95201 - <br /> Received by -- <br /> APPLIGANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITfSERYlCES <br />