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Applications win He Processea wnen suomntea Properly completes. lie sure to Slgn I ne Application. <br /> FOR OFFICE USE: APPLICATION <br /> -_,or Non-Transferable, Revocable,Suspendable) / PUIVILP&WiZi_L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or installthework herein described.This application is <br /> made in compliance itt�Sn Joaquin Count Ordinance No. 1862 and the rules and regulations of the San Jo in Loc I, Ith District. <br /> Exact Site Addres 1 7"17City/Town,�y <br /> Owner's N e Phone <br /> Address City <br /> Contractor's Name License M„ cam' :%5,la Business Phonrei �n <br /> Contractor's Address �f� d� m"`'�- Emergency Phone U l <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes_� No <br /> TYPE OF WORK (CHECK): NEW WELL 11 DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIR❑ <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 <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> .DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information �^ <br /> ❑ GEOPHYSICAL Suu ace Seal Installed By: s} <br /> PUMP INSTALLATION: Contractor / I/h'r <br /> Type of Pump_" H.P. A' <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 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> �j1�111 1 for a Out Ins to for tc groJutJl�g and a final Inspect�n_. <br /> Sign /X/- � <br /> (Draw Plot Plan on Reverse Side) <br /> rN�f��FOR DEPARTMENT USE ONLY 1 �f <br /> PHASE 1 ` -� �� \„� �� '(JL{ Date " 9A <br /> Application CommenAcceptets:By_- -�- + �] <br /> Additional Comments: <br /> Phase 11 Grout Inspection ase III FinalInss�tion <br /> Inspection By It Date Inspection By-` 9wr'aDate ld ,�Z <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE 8 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I uence to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 18011 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />