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Applications Will Be Processed When Submitted Properly Completed. g { <br /> FOR OFFICE USE: { APPLICATION Al 6 1 <br /> _ (For Non-Transferable, Revocable,5uspe ) �p\� r �'&WF{L <br /> ENVIRONMENTAL HEALTH PER IT t `F�'ti� ,S` + <br /> { WATER QUALITYN! A\A <br /> (COMPLETE IN TRIPLICATE) it aoY <br /> tt �Ol herein described.This application is <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinst <br /> made in compliance with San Joaquin County'Ordinance No. 1862 and the rules and regulations of the San Joaquin Lo al Health District. <br /> City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name City <br /> Address License# Business Phone I <br /> Contractor's Name <br /> Emergency Phone <br /> Contractor's Address v No f <br /> Is Certificate of Workman's Compensation Insurance on Filg With SJLHD? Yes <br /> DESTRUCTIONO <br /> TYPE OF WORK (CHECK):'.❑ WE W ABA�ONMENT ❑❑ OTHER 0 RECONDITIONPUMP INSTALLATION �� PUMP REPAIR❑ <br /> WELL CHLORINATION <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines y <br /> Cesspool/Seepage Pit Other <br /> Cess <br /> Sewage Disposal Field p <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 0E DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> C1DOMESTIC/PUBLIC ElDRIVEN i� Gauge of Casing ! <br /> 01-FIRIGATION ❑ GRAVEL PACK Depth of Grout Seal i 4 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> C ❑ DISPOSAL <br /> ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL 5 face Seal Installed 13y: I <br /> fJ <br /> i PUMP INSTALLATION: Contractor <br /> Type of Pump H P <br />€ PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> Well Diameter Approximate Depth <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <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 signature certifies the following:"I certify that in the performance of the work forwhich this per <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 emplo l persons subject to workman's compensation laws of California." <br /> I will Caa for a Grout I ction prior to grouting and a final inspection, <br /> Title: —T <br /> 1e "-.:. Date: <br /> Signed X <br /> {Draw Plot Plan on Reverse Side) <br /> FOR DEPARTM NT USE ONLY /.. <br /> PHASE I Date ` Z-y <br /> fl <br /> FAppiication Accepted By <br /> Additional Comments: Ph se II Final Inspection <br /> P as 11 Grout Inspection Date Inspection By Date <br /> Inspection By _ - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveFld.EBy July 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> .BASE EXPLANATION DATE DATE RFMVTTED AMOUNT <br /> FEE <br /> r <br /> i LESS <br /> PRORATION <br /> PLUS + <br /> PENALTY <br /> I OTHER <br /> OTHER r) <br /> f <br /> Received by Date <br /> Receipt No. s Permit No. � Issuance Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.box 2009 STOCKTON,CA 95201 <br />