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I Applications Will Be Processed When Submitted Properly Completed. BeSureToSignTheApplicallon. <br /> i Fof� OFFICE USE: APPLICATION <br /> ,For Non-Transferable, Revocable, Suspendable, / p�jMp&WALL <br /> t ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ermit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health Districtfora p <br /> made in complian�ce <br /> with an Joaqui County Ordinance o, 1,862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address o� City/Town <br /> Owner's Name A4 Phone <br /> Address — City <br /> Contractor's Name License# Business Phone_ <br /> r <br /> IContractor's Address mergency Phone <br /> A Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes ✓ No <br /> TYPE OF WORK (CHECK): NEW WELLq�-' DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> I REPLACEMENT❑ <br /> } DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field /4;0 —_ Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL " <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> EVDOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casingf <br /> 11IRRIGATION [F GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION �OTARY Type of Grout gA <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> F 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 /> prepared 1 hereby certify that PP <br /> I have re ared 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:1 certify that in the performaceof thework forwhich 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 /> ' twit cab for a Crro Inspe tion prior to grouting a�an <br /> final Inspection. <br /> Signed X Title: Date T <br /> {D w on Reverse ide) <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> j PHASE I <br /> Date <br /> Application Accepted By <br /> I Additional Comments: <br /> P a I Grout Inspection �3 5 y Phase IIS Final Inspection <br /> Inspection 8y Date d Inspection By 4��pJ� Date <br /> Fee Is Due: C3 ANNUALLY ❑ PER UNIT El PER SITE © EACH C1 January 1 &Received By January 31 ❑ July 1 &ReceiveR�EMIBy Tuly 31 <br /> BASEtEXPLAEXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE :�RE:Ml'T�TED AMOUNT <br /> f <br /> FEE —� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> " OTHER <br /> i <br /> r OTHER <br /> Lk <br /> Received y I Da4 Receipt Na. Permit No. Issuance Date Mailed - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2409 STOCKTON.CA 95241 <br />