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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: k APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) PLUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> OMPLETE IN TRIPLICATE} WATER QUALITY <br /> (C <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 r <br /> made in compliance.with Sn Joagruirn ounty Ordina ce No. 186 and the rules and regulations of the.San Joaquin Local Health District. <br /> Exact Site Address rV `� -04 City/Town <br /> Owner's Name Phone ` ' 4 <br /> City `iFT�rr�./J7G1 r <br /> Address l ! + <br /> Contractor's Name =" Lidertse# B siness Phone'�f �* <br /> Contractor's Address =Emergency Phon <br /> Is Certificate of Workman's Compensation Innsurai on File With SJLHD? Yes No ; <br /> TYPE OF WORK (CHECK): NEW WELL WY DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ { <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy it <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL f <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 12'DOMESTIC'i/PRIVATE ❑ DRILLED - Dia. of Well Casing 64 <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ 9J PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION L� ROTARY Type of Grout 4r <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of PumpPUMP <br /> t PUMP REPAIR:REPLACEMENT: © State Work Done _�-/� U p `'�� <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> � r <br /> I <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 /> Home owner or licensed agent's Isignature 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 /> fContractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhi�chthis <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> i call or.a Grout Inspection to gropi and ' inal inspection. <br /> Signed X All Title: - Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By <br /> Additional Comments: _ 7 <br /> Phase II Grout Inspection _ Phase III Final I spection <br /> 9 of Date " 3 4 Inspection By Date <br /> Inspection By <br /> d By <br /> Fee is Due: ❑'ANNUALLY 12PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 -❑-July 1 &ReceiveREMITuIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMOUNT <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> r <br /> OTHER <br /> 3 7 <br /> - Date Receipt No: -� t Permit No.,-r I uance ate Mailed Delivered <br /> Received by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTDN,CA 85201 J-.- <br />