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Applicati acessed When SubmittedProper+y �omN���..• ~` _ <br /> M-- <br /> APPLICATION <br /> (For Non-Transierable, Revocable, Suspendable) p(1MP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT 230 —/�WATER QUALITY lication is(COMPLEIN TRIPLCATE} n Lo I He Ith District. <br /> Application isher�ebymadetotheSanJoaquinLocalHealthDistrictfor dphe permit <br /> andrregulaaoona oftthe Sana;I the ork herein described.This app ' <br /> Applic 6 / I <br /> made in compliance with San Joaquin Cou t Ordinan •j$. - ,-I City/Town <br /> Exact Site Address t Phone i <br /> Owner's Name _ City y <br /> Address License# Business Io ev1O <br /> Contractor's Name gency Phone l <br /> Contractor's Address No <br /> is Certificate of Workman's Compensation Insurance on File With JLHD? Yes ❑ DESTRUCTIO � ��..-- <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION w PUMP REPAIR❑ <br /> REPLACEMENT❑ Sewer Lines Pit Privy Other <br /> Cesspool/Seepag <br /> DISTANCE TO NEAREST: Septic Tank e Pit <br /> li <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL 11 DRILLED Dia. of Well Casing h <br /> ❑ DOMESTIC/PRIVATE Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN �t <br /> GRAVEL PACK Depth of Grout Seal <br /> 11 IRRIGATION 13 ROTARY Type of Grout G <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface Seal Installed By: Q <br /> i ❑ GEOPHYSICAL <br /> _ Contractor H.P. � <br /> f PUMP INSTALLATION: Type of Pump r <br /> ❑ State Work Done ' <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Approximate Depth 00 <br /> DESTRUCTION OF WELL: <br /> Well Diameter .S <br /> .Describe.Material and Procedure , <br /> t certif that lµhave prepared this application and that the work will be done in accordance with San Joaquin County <br /> th District. <br /> I hereby Y <br /> - ordinances, state laws, and rules and regulations of the San JoagGler certifyLocal <br /> than ntlheperformanceoftheworkforwhichthis permit -� <br /> Home owner or licensed agent's signature certifies the following:" Y <br /> is issued, I shall not employ any person in such manner as to.become subject to workman's compensation laws of California. <br /> Contrac <br /> tor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this S <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." i <br /> I will call fora Grout I sp tion prior to grouting and a final inspection. Date. <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> F DEPARTME USE ONLY <br /> Date <br /> 111 PHASEI <br /> Application Accepted By <br /> Additional Comments: a 111 final inspection <br /> Phase li Grout InsP onDate V <br /> Inspection By <br /> Date inspection B <br /> 1 &R ived By January 31 ❑ July i &Received 6y Jufy 31 <br /> January REMIT <br /> Fee is Due: ❑ ANNUALLY <br /> C1 PER UNIT El PER SITE. El EACH $ AMOUNT DUE CHECKED <br /> BILLING REMITTANCE REMITTED AMOUNT <br /> BASE EXPLANATION DATE DATE <br /> ✓ C <br /> FEE <br /> LESS <br /> PRORATION .. F <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> �� ' aA 3suarn�ce Dates Mailed Delivered <br /> Receipt No. PerrniS No, <br /> 1 e eived by ate - 1601 E.HAZELTON AVE,,P.D.Bax 2009 STOCKTON,GA 95261 <br /> ENTAL HEALTH PERMIT/SERVICES <br /> .Do,IrewT—RETU N ALL COPIES TO: ENVIRONM <br />