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FOR OFFICE USE: l APPLICATION rr <br /> Z, Revocable, Suspendable) <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 Con.siruct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Or 'nance No: 1862 an the suies-and regulations of the San Joaquin Local eatth District. <br /> Exact Site Address City/Town <br /> Owner's Name Phone <br /> .-.Address 1,2.A t 041City <br /> Contractor's Name :License# Business Phonef!V%2 �Z p <br /> Contractor's Address _ Emergency Phone <br /> is Certificate of Workman's Compensation Insurance on File With-SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑, <br /> WELL CHLORINATION.❑ WELL`ABANDONMENT ❑ OTHER ❑ _'PU`MP-INSTALLATION fl ""'PUMi'REPAIq <br /> REPLACEMENT❑ •, I <br /> ,DISTANCE TO'NEAREST:, ;Septic Tank Sewer Lines pit Privy p1� - <br /> -_ ewageDisposal Field Cesspool/Seepage Pit Other <br /> z "Pzoperty Line '"Private Domestic Well Public Domestic Well <br /> INTENDED-USE .'a ... : TYPE:OF.WELL r <br /> ❑ INDUSTRIAL 'O,CASLE TOOL ' Dia:of Well Excavation+ t <br /> 'XDOMESTIC/PRIVATE ❑.DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN _ .. .. v.:Gauge of Casing <br /> ❑ IRRIGATION ❑.GRAVEL PACK "Depth of Grout Seal <br /> ,Q,CATHODIC-PROTECTIONS.t❑_RO.T.ARY;;�_r; ^ Type of Grout_ <br /> ❑TDISPOSAL [] .OTHER ,Other,e formation, > <br />,.^,,...❑_GEOPliYSIC-AL ,. - �,.�, ' _seal�lnstallLydBy: j <br /> -PUMP INSTALLATION: Contractor <br /> { .. Type of PumpScl�- _ H.P. JK <br /> 'PUMP REPLACEMENT: .: ❑ State Work Done � <br /> PUMP REPAIR: - State Work Done <br /> DESTRUCTION OF WELL:_:. € 'E-Well Diameter Approximate Dept 'n <br /> - Describe Material and Procedure <br /> °hereb y.certify that.t.have-.prepared.this ryapplication and that-ther work.will be done in accordance with,San Joaquin County <br /> ordinances, state laws, andru les and regufatlons of the San Joaquin Local.Health District. �; <br /> Home owrlertir I1cet48edagen!Asignature certifies the following:"f certitythat in the performanceof.thework for which this permit �� <br /> is issued, t shall not employ-any-person_in such manner as to-become subject to workman's compensation laws of California." r <br /> - ContractoYs hiring or sub-contracting signature certifies the following:"I certify that in the pel�ormance of the work for which this <br /> - permit is issued, I shall-ernploy.-,persons'subject to workman's compensation laws of Califamia.':.... <br /> I will call toua`Grout Inspec v rfor Jo_gfc and a final inspec6on. .- } <br /> 1 <br /> i . Signed GI — le: - Date- <br /> r (Draw Plot P n on Reversei Side), <br /> ._FORS DA rMENT USE ONLY <br /> -...:PHASE I <br /> 1` } <br /> Application Accepted By """ Date <br /> Additional Comments: - " <br /> -w <br /> phase 3i lrr'out 1nsPttetionP -ill I-tnsp tion ,Q <br /> -Inspection By 1 ` Date Inspectio?eceived <br /> Date <br /> Fee Is Due: ElANN17Atilt^�:"" ❑ PER UNIT "'fl PER'SrrE- El EACH ❑ January 1 By January 31 C1 Jdly 1 6 Received By July 31 <br /> BILLING REMITTANCE T REMIT <br /> I <br /> BASE -`" EXPLANATION - AMOUNTTDUE t ,CHECKED DATE DATE REMITTED <br /> �- AMOUNT ._ <br /> f FEE <br /> LESS <br /> S <br /> .PRORATION <br /> t <br /> PLUS <br /> r PENALTY - - - <br /> i; OTHER <br /> OTHER c <br /> 29--&6 <br /> Received by Date Receipt No. Permit No. . Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601E.MAZELTON AVE..P.O.Box 2009 STOCKTON.CA 95201 <br /> ,w8 <br />