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4 .+pprrsanonsWill eyeProcessedWhenSubmitted`Properly.Completed. Sur�Sign The dppltcation. <br /> I-1. F.QW FFICE USE: ?" <br /> –APPLICATION FE'8 111980 <br /> t (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SAN J0pQb11WF,60'. <br /> k (COMPLETE IN TRIPLICATE) '• WATER HEALTH DISTRICT <br /> 5_ S.T� QUALITY ,25 o---0410 C� <br /> Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work herein described.This application is <br /> r made in compliance with San oaquin ounty Ordinance No. 1862'and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 00,,City/Town <br /> F Owner's Name MA 0' Phone <br /> Address — 810- 16- K <br /> I <br /> Contractor's Name /�—�Lt_� L_rb— A��'LLicerise# Business Phone <br /> Contractor's Address _� O Emergency Phone Phone— <br /> Contractor's <br /> Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELL 9?"� DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> i REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 00 <br /> P Sewer Lines 100 Pit Privy �— <br /> ` Sewage Disposal Field 017Cesspool/Seepage Pit .rte" Other— <br /> Property Line � Private Domestic Well -� <br /> Public Domestic Well . <br /> INTENDED USE TYPE OF WELL !� <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation i <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> 160 4,Ez! <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION <br /> ROTARY Type-of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information l <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump r <br /> PUMP REPLACEMENT: ❑ State Work Done H.P, <br /> PUMP REPAIR: ❑ State Work Done R + <br /> DESTRUCTION OF WELL: 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 1!'✓ <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District, r <br /> Home owner 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 miring 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 /> j <br /> I will call for a Grout Inspec 'on prior to grouting and a final inspection'. <br /> YSigned X . Title: Date: Z� <br /> �,a. Plt on Reverse Side) <br /> FOR DE ARTMENT USE ONLY <br /> PHASE [ <br /> 7 r <br /> Application Accepted By Q [ Date �d <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III f=inal Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Receiv 6y January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REWT <br /> DATE DATE REMITTED rAMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> _ r <br /> PLUS <br /> PENALTY <br /> 4 <br /> OTHER <br /> l OTHER - <br /> . <br /> Received by Date Receipt No. Permito. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box.2009 STOCKTON,CA 95201 <br />