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Applications Will Be Processed When Submitted Properly Completed. Be Sums fA 6.9-in ALe)App4ica4(A1. <br /> FOR OFFICE USE: APPLICATION Ll ; <br /> For Non-Transferable Revocable,'Suspend{ � P 7 �/J&filELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I t) :7�(L <br /> (COMPLETE IN TRIPLICATE) Z2_ s/+� #-L E.4 W T R QUALITY <br /> s 3 I J <br /> Application is hereby made to the San Joaquin Local Health District fora permitto construct and/or install W33tA6TtWreitS1d% cngeTThis application is <br /> made in compliance with San Joaquip C unty Ordinance No. 6.an the-rule�ru opsof the San J aquin Lo al Health District. <br /> Exact SiteAddress �fCity/Town <br /> Owner's Name _ t .Esc. '} ' _ Phone <br /> Address W-.• City VL <br /> Contractor's Name License# 3 2 7 Q Ul�3usiness Phone <br /> Contractor's Address uLj. Emergency Phone 's <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL K DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION PUMP REPAIR❑ <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines_�JQ Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other— <br /> Property <br /> ther Property Liners Private Domestic Well Public Domestic Well "'G <br /> INTENDED USE TYPE OF WELL <br /> I ❑ INDUSTRIAL ❑ CABLE TOOL -Dia. of-Well Excavation 1_ <br /> r <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> © i i <br /> 13 IRRIGATION 11 GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION 0ROTARY Type of Grout <br /> 4 ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: 17 C;I <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> t <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 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 /> Home owner or licensed agent's signature certifies the following:"I certify that 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I or a Grout Inspection prior to grouti anZaal inspection. <br /> Signed X. itle: Date: _40 <br /> (Draw Plot Plan on Reverse Side) <br /> E FOR DEPARTMENT USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection / Phase III Final Inspection <br /> f �s - I /i� �jJ In By 1•�—r� � Date <br /> Inspection By-?tDate� . <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 Received By July 31 <br /> - - REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE /Vd d�ny�q[F rlxA 7�ie+�Ai l <br /> LESS 6 Ir! v cor�cc fax y -e¢l� <br /> PRORATION <br /> PLUS <br /> PENALTY ' <br /> OTHER <br /> OTHER <br /> -= Received by Date ..Receipt No. - Permit No. Assuarrce Dae Mailed Delivered' -- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE,,P.O.Box 2009 STOCKTON,CA 95201 <br />