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Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> FOR OFFICE use: APPLICATION <br /> (For Non-Transferable, Revocable, Suspend�a1ble) <br /> ENVIRONMENTAL HEALTH PERMIT- <br /> (COMPLETe IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work.herein described.This application is i <br /> made in compliance with San Joaquin Count Ordina ce No. 1862 and the rules and regulations of the San Joaquin Local Health District. i <br /> Exact Site Address L � " �� City/Town <br /> Owner's Name _5 Lt7 —0 A) Phone <br /> Aim City <br /> Address <br /> Contractor's Name VS License# 3rl� Business Phone 9– -5Z <br /> Contractor's Address r ti Q 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 �}j <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 z <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> 13 DOMESTIC/PUBLIC 11 DRIVEN Gauge of Casing <br /> 4 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> I <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done *0 <br /> PUMP REPAIR: ;9 State Work Done <br /> DESTRUCTION OF WELL: <br /> 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 /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> 1 will call for a Gro Inspection prior to grouting and a final inspection. <br /> Signed X a Title: Dale: <br /> T— (Draw Plot Plan on Reverse S e) S �„� a scz- Aly <br /> 1 FOR DEPARTMENT USE ONLY 11[�!�✓Q <br /> PHASE 1 1 q <br /> Date <br /> Application Accepted By <br /> Additional Comments: r <br /> Phase 11 Grout Inspection a 111 final Inspection� �/� <br /> Inspection By` Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY 1 ❑ PER UNIT'- PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By.,Ju1y 31 <br /> REMIT ' <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r.' <br /> FEE 0• �!� <br /> r <br /> LESS <br /> l PRORATION F <br /> E{f PLUS <br /> PENALTY 7 <br /> OTHER ` <br /> OTHER <br /> ?Z, <br /> r Received by Date Receipt No. Permit No. IssiJance Date Mailed Delivered <br /> IAPPLICANT—RETURN ALL COPIES TO: ENYiRONMENTAL HEALTH PERMIT/SERVICES ifi01 E.HAZELTON AYE:,P.O.Bax 20U9 STOCKTON,^A 95201 <br />