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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FO%GFt`11rE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) a. <br /> F_ Y.TWELL <br /> ENVIRONMENTAL HEALTH PERMIT jt1\ <br /> (COMPLETE IN TRIPLICATE) s _ WATER QUALITY l�,a 35V <br /> Application is hereby made to the San Joaquin LocalrFlealth District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Jo�ui C ty r ma N9 1862 and the rules and re do s of then Joaquin Local Health District. <br /> Exact Site AddressA<I ,$/d[ /►yt �Ylt �d, o- A��dvn <br /> J r S 1 <br /> Owner's Name .3 Phone <br /> Address •3 City <br /> Contractor's Name 11AW License# Business Phone <br /> Contractor's Address ©f7,-C�.. Aed IJ Emergency Phone x <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL ' DEEPEl❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONM `'OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR <br /> REPLACEMENT❑ ' „ � <br /> DISTANCE TO !NEAREST: Septic Tank "� Sewer Lines c�� ^� Pit Privy <br /> Sewage Disposal Field/D Cesspool/Seepage Pit _ Other — <br /> Property Line /© wl� Private Domestic Well -CO- 1-4 Public Domestic WellI <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ABLE!TOOL pia, of Well Excavation <br /> ❑ DOMESTIC/PRIVATE .r� `�"C ILLED Dia. of Well Casing f� � <br /> ❑ DOMESTIC/PUBLIC __1'13:.D.RfVEN Gauge of Casing <br /> KIRRIGATiON ❑ GRAVELL RACK Depth of Grout Seal LE <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout V� <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL ,t � <br /> j Surface Seal Installed By: r. 7 �. <br /> PUMP INSTALLATION: Contractor tr(J dt-Li <br /> t <br /> Type of Pump !✓ _ . _.. H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <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 <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 performanceof 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 G put In echo r' r to grouting and a final inspection. <br /> / j . 1 <br /> Signed X Title: 1JACA141 Date: <br /> (Draw Plot Plan on Reverse i ) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phas IlgwJl Final Inspection <br /> Inspection By Date Inspection By��, (//'////�� Date <br /> Fee Is Due: C3 ANNUALLY ❑ PER UNIT El PER SITE C1 EACH © January 1 &Received By Jaf�uarye31 ❑ July 1 &Received By July 31 <br /> BILL#NG REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> '0 _ <br /> Received by Date Receipt No, Permit No. if Is uance 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 />