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r Applications Will Be Processed WhenSubmitted Properly Completed. BeSureToSign TneApplication. <br /> FOROFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) UMP&WELL <br /> G <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rufles and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 515/ A) "!�I-v "ILL1 I•t7 City/Town ec:lfftjyl <br /> Owner's Name ` -,e E� Phone .3 <br /> Address IT/ q City ?)0e <br /> Contractor's Name QC e ?"W112ce License 9333-J-13 Business Phone 9 ye-W7 <br /> Contractor's Address E Emergency Phone q41 90 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X 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 Weil <br /> INTENDED USE TYPE OF WELL a <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> IRRIGATION ❑ GRAVEL PACK r Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY . Type of Grout 5A <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor ki OCL C"e 0 <br /> Type of Pump J"V i Yt,.e- H.P. <br /> PUMP REPLACEMENT: ❑ State work-Done X r <br /> PUMP REPAIR: ❑ State Work Done %4ra <br /> i <br /> DESTRUCTION OF WELL: Well Diameter y Approximate Depth 4 <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 /> Homeowner 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 /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X ®id S L "• :Title: 4'1Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMEN USE ONLY <br /> PHASE <br /> Application Accepted By e Date /4-�4,pU <br /> Additional Comments: <br /> Phos 11 Grout Inspection Phase III Final Inspection <br /> is <br /> Inspection By Date Inspection By "--Plate -3 �U <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1*&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DAT DATE REMITTED AMOUNT <br /> { 1 <br /> FEE � <br /> LESS <br /> PRORATION r G- <br /> ✓` <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No 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 ne^^' <br />