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a Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The ratio t <br /> old OFFICE USE: APPLICATION <br /> (Fpr Non-Transferable, Revocable,5uspendable) —TM7- E ----�-�--� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is herebymadeto the San Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is <br /> made in compliance with San JoaqCou ty Or inance No. 1882 and the rules and regulations of the San Joa uin Lo al Health District. <br /> Exact Site Address �� ui City/Town <br /> Owner's Name 9vilo 4e, Phone <br /> Address City <br /> Contractor's Name License# Business Phone /Q <br /> Contractor's Address ��D j,� a_ 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 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 /> ©�fNDUSTRIAt_ ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing f <br /> ❑ DOMESTIC/PUBLIC-a- - ----- ❑ DRIVEN .-, - _ Gauge of Casing - <br /> ❑ IRRIGATION r '� ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Su ace S al Installed By: <br /> PUMP INSTALLATION: Contractor <br /> ,Type of Pump 4,4 <br /> PUMP REPLACEME=NT: L'f State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure -Z <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County O <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 /> i permit is issued, I shall employ,persons subject to workman's compensation laws of California." <br /> i <br /> 1 will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: _' ���� Date: �-0? <br /> (Draw Plot Plan on Reverse Side) <br /> i FOR DEPARTMENT USE ONLY t <br /> PRASE I 1 <br /> Application Accepted By 4 f f y Date_... 10Ck <br /> Additional Comments: t <br /> Phase II Grout Inspection t - Phase at Inspection , <br /> Inspection By 1l'>i Date t Inspection By /'"r Date 9 <br /> Fee IS Due:❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑ EACH ❑.January1 R Received By January 31 ❑ July 1 B Received By July 31 <br /> REMIT <br /> F BILLING REMITTANCE $ <br /> SASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �p AMOUNT <br /> FEE `r4 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ._� .. _....-.. _ .. .-- - ...._.. <br /> Received by Date Receipt No. Permit No. Issuancq Dale L Mailed Delivered J <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.D.Box 2008 STOCKTON,CA 95201 CO <br /> !f <br /> t <br />