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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign Tinpfication. I ) I I i <br /> FOR OFFICE USE: APPLICATION �� 24 19BI ��,� <br /> (For Non-Transferable, Revocable;Suspendable) PUAAP& LL <br /> ENVIRONMENTAL HEALTH PERMIT SAN i0AQU11N LOCAL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY Ek�-YH ®ISTF�ICT <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance wit Soman Joaquin County Ordinance No. l_62 and the rules and regulations of the San Joaquin L c I Healtr7�trict. <br /> Exact Site Address_ (� /// T J �- City/Town <br /> Owner's Name = Phone <br /> Address City F <br /> Contractor's Name -Li ense# B i esrss Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes 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 tines 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 I <br /> ❑ IjC7USTRIAL ❑ CABLE TOOL Dia. 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 /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br />' <br /> IJ ❑ OTHER Other Information <br /> I <br /> j ❑ GEOPHYSICAL Surface.Seal Installed By: <br /> PUMP INSTALLATION. Contractor <br /> Typ f Pump N.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 /> t <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. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 /> 4 - permit is issued, I shall employ$ersons subject to workman's compensation laws'oi California." <br /> I call or a Grout Inspection or to gro ng and inal inspection., <br /> Signed X Title: Date: <br /> (Draw lo Ian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY t <br /> t <br /> PHASE 1 m F <br /> Application Accepted By + Date <br /> Additional Comments: <br /> t � <br /> ` <br /> Phase II Grout Inspection �j`. base 111 Final Inspection <br /> . ..� 6y—,, V7 <br /> Inspection By Date Inspection ' I pate i <br /> Fee Is Due: 0 ANNUALLY ❑ PER!UNIT ❑ PER SITE t. ❑ EACH` ❑ January 1 &Received By January 31 - ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING' .REMITTANCE - $T� AMOUNT DUE CHECKED <br /> BASE EXPLANATION PATE ° DATE REMITTED AMOUNT <br /> FEE - <br /> --A n e <br /> LESS ' <br /> PRORATION <br /> PLUS <br /> PENALTY - - <br /> OTHER f' <br /> OTHER <br /> 133,S3 9 Q:9 <br /> Received by Date Receipt No. Permit.Na. I uance ate Mailed Delivered <br /> — APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTTON AVE..P.O.Box 2009 STOCKTON,CA 95201 <br />