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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OfflipE USE: APPLICATION 1 <br /> i <br /> - . (For Non-Transferable 'e► Lie;Suspendable) 1,�QIMP&WELI <br /> ENV IRQNMENTAL_HEALTH PERy <br /> ,, j <br /> 5. "'i'. U� 1f1 l <br /> -� WATER UALITY <br /> (COMPLETEAN TRIPLICATE)'[-:5 ZT 'S- «�.���-�..rs Q -.r - 4,r..,;<- , 'Application is hereby madetotheSanJoaquinLocalHealthDistrictforapermittoconstruct �lhework herein described.This appikationis 1) <br /> made in compliance with San Joaquin Cou ty Ordinance Nrv- <br /> o. 1862'and the/i'"rules and` a tions of the San Joaquiri Local Health Iistrict <br /> Address*a �i -jam' O �Clty/Town <br /> Exact Site - 0 <br /> 2,35 <br /> Owner's Name !>" ,�S: Z3 {76 Phone, t <br /> Address r�_ •.�' �, City <br /> " r` _-' LiBusinet;s"P.hone` <br /> Contractor's Name cense# <br /> s � - K. ;in-,* <br /> - *Em_ergency Phone. . -..r• x <br /> Contractor's Address - . _ <br /> Is Certificate of Workman's Compensation In urance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELD DEEPEN ❑= --RECONDITION❑"_ DESTRUCTION❑- = -` ^' ` " - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT.❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 01 <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank _ 111�'Y11t Sewer Lines Pit Privy <br /> Sewage Disposal Field /7017°e- Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL r/ <br /> s ❑ INDUSTRIAL i_. ❑ CABLE TOOL Dia. of Well Excavation f ry <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia.-,of Well,Casing V <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing" °7 <br /> ❑ IRRIGATION v _ GRAVEL PACK Depth of Grout Seal7— <br /> ❑ CATHODIC PROTECTION ROTARYType of Grout <br /> ❑ DISPOSAL ❑"OTHER Other lnformatio,n d <br /> ❑ GEOPHYSICAL ,... Surface Seal Installed By: l <br /> PUMP INSTALLATION: Contractor <br /> i - w <br /> Type of Pump H.P. - (p <br /> } PUMP_REPLACEMENT: ❑ State Workk-Done - <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: "r - �" Well Diameter Approximate Depth <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 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 /> Contractors 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 employ persons subject to workman's compensation laws of California <br /> I will call for a.prout In ect' prior to groutin and a.tinal 'nspectian. <br /> Signed X. Title: _ Date: <br /> (Draw P t P an on Revers Side) <br /> F FOR DEPARTMENT USE"ONLY <br /> PHASE I <br /> Application Accepted By l L Date 1Z <br /> Additional Comments: <br /> e r It Inspection ° ', T" Phase ill Final"inspection <br /> Inspection By Date , Inspection.By Date <br /> 1 Fee Is blue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑•EACH ❑ January 1 &Received By January 31. ❑ July 1 &Received By July 31 <br /> f REMIT <br /> i BASE - EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED " <br /> DATE DATE REMITTED AMOUNT <br /> FEE qL <br /> - <br /> LESS t <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER a <br /> OTHER - <br /> DL <br /> Received by to 'Receipt No. . . - .Permit No. lssua ce Datel Mailed„ Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />