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Applications Will Be Processed When Submitted Properly Completed. Be Su`e'JJr S#4n�YheAppllcation. <br /> FOR OFFICE USE: APPLICATIONr, `� g N2 �P✓ <br /> I (For Non-Transferable, Revocable,Suspendable) `p IVtFs&WELL . <br /> c I <br /> ENVIRONMENTAL HEALTH`PERMIT SAN' LOCAL - V <br /> (COMPLETE IN TRIPLICATE) .WATER QUALITY r;' I: HEAL :y,# t _ :- . <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 with-S Jn Cc ntyOrdina a No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address City/Town - <br /> Owner's Name `; "= Phone <br /> Address City <br /> Contractor's Name r Liceirse#' usiness Phdn'e' t <br /> Contractor's Address -L eigency Phohe <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? _Yes '� No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION u DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <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 /> ❑.,�DUSTRIAL 13 CABLE TOOL Dia. of Well Excavation <br /> U' DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACKDepth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout A^ <br /> ❑ DISPOSAL 11 OTHER Other Information V" <br /> ❑ GEOPHYSICAL :Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: El State Work Done # <br /> PUMP REPAIR: P'State Work Done ACounty : <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure'I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqui <br /> ordinances, state laws, and rules'and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which t <br /> is issued,.1 shall-not employ any person in such manner as to become subject to workman's compensation laws of California." J <br /> Contractor's hiring or sub-coniracting signature certifies the following:"I certify that in the performance of the work toe whi h thi f <br /> permit is issued, I shall employ persons su ject to workman's compensation laws of California." <br /> I w a Grout Inspec ' prior groutin d a final inspection. <br /> Signed X A4 i7 Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> 1XII FOR DEPARTMENT USE ONLY /I t <br /> 6`jJ I" <br /> PHASE F ` <br /> Application Accepted Bate � 1 <br /> Additional Comments: )I <br /> Phase II Grout Inspection Pe III Final Inspection <br /> Inspection By -- % Date Inspection By ate 6— 7'�2 <br /> F <br /> y r <br /> Fee Is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING_ REMITTANCE $ AMOUNT DUE CHECKED <br /> �I DATE DATE REMITTED AMOUNT <br /> FEE \ <br /> LESS g ' <br /> PRORATION 11 - <br /> PLUS <br /> PENALTY <br /> OTHER I <br /> OTHER <br /> _ S4 <br /> Received by - Date Receipt No Permit N o. Uuance Uate Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Box 2U09 STOCKTON,CA 95201 <br /> APPLICANT�RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />' rl <br />