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'ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, r. <br /> FOR OFFICE-USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) ` <br /> 1 ENVIRONMENTAL HEALTH PERMIT DUMP&WELL , <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health district fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San JoaquinCounty Ordinance No. 1862 and the rules and regulations of the San Joaquin Local H alth District. <br /> Exact Site Address Q 2.0 ttl(s Y99City/Town IR <br /> s7 0� <br /> Owner's Name d IR � `C.� Phone131 - 01+3 <br /> '"- <br /> Address ����b � <br /> Contractor's Name C t <br /> vu--, <br /> License # Busineshone 'if �ZContractor's Address �+QZ+ Emergency Phone _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes Lewf� No 1 <br /> TYPE OF WORK (CHECK): NEW WELL�► DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑-. <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank . Sewer Lines Fait Privy . �. <br /> u:Y .._-. ��:,_,_�.....�....a...�FSewageAasposal-Field_w.._,�.��__...:.:..CesspooflSeepagePlt_'".:, ;.__....._:�:.w.. 04her-•--'_ _--,......:..,..,._.-..._-_..._.��...... <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation SY <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing C.l. 140 VC, <br /> IN IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information ' <br /> ❑ GEOPHYSICAL _. _ —Surlace-SealJnslalJed.B.y_.. R <br /> PUMP INSTALLATION: -s�- Contractor ; <br /> Type of Pump ry H.P..._ _ <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter,_ _, <br /> ..Apprpximi;#e Depth <br /> Describe Materiai'arid'ProcedureF-A 1 <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 thework for which thispermit <br /> is issued,.I shall not employ e <br /> p y an y person in such manner as to become subject to workman's corr�pensns <br /> atiol�-laws pf.Caljfornia." <br /> C traclur's hir1W or sub-contracting signature certifies the following:"I certify that in the performance.of tlie'work"for whicFi this <br /> AW <br /> employ ersons ubject to workman's compensation laws of California."," r ` <br /> i prior-to rout!ng-and-a-final-inspection-- <br /> Signed <br /> inspectionr,,;-- <br /> LUAW <br /> Signed X Title: iFl p ate: . <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � s 4 <br /> Application Accepted y_ Date 3Z f <br /> Additional Comments. ; <br /> t <br /> Phas II Grout Inspection Phase I!I Final Inspection <br /> Inspection By Date Inspection By Date ' <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE ❑ EACH 13 January 1 8 Received By January 31 El July 1 8 Recelyed By July 31 <br /> BILLING REMITTANCE $ ! REWT <br /> BASE - EXPLANATION AMOUNT DUE CHECKED <br /> t DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION [� <br /> y PLUS <br /> PENALTY <br /> OTHER <br /> re,, I� <br /> OTHER etiAf <br /> ly ��' <br /> O <br /> IS7 1 �0 �01L?L <br /> Received by Date i Receipt No Permit No. Iss ante Date_µy Mailed Deliveretll let <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - _ _.1601.E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 9 <br />