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Applit:ations Will Be ProcesssseeJ When submitted Properly Completed. Be Sure gn The Application. ,W <br /> FOR-i3FF10E USE: t 1 APPLICATION I DEC 13 1979 <br /> '1For Non-Transferable, Revocable,Suspendable) i <br /> ENVIRONMENTAL HEALTH PERMIT SAN JOAQi D W <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY HEALTHJ <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address I d 2(OU w sS'T kp,yK City/Town 5 T0i!�4--7-e3 1.11 <br /> Owner's Name Phone <br /> Address �� - ��'— City <br /> Contractor's Name r�AA&LLa C)e-, �V►ll� License#3r1''7[yl Business.Phone C3t7 <br /> Contractor's Address 2�_A 0 _J M 0 Emergency Phone -14 i(e f , �"{,U _ <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes h No " <br /> TYPE OF WORK(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> 1 Sewage Disposal Field Cesspooi/Seepage Pit Other <br /> j Property Line Private Domestic Well Public Domestic Well <br /> 9 INTENDED USE TYPE OF WILL <br /> ❑ INDUSTRIAL ❑ CA13LE TOOL Dia. of Well Excavation IN, <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing g.:] <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: tt`' <br /> PUMP INSTALLATION. Contractor <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 <br /> i 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 /> Homeowner 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 for which this <br /> l <br /> permit is issued, I shall employ ersons subject to orkman's compensation laws of California." <br /> will cal for a Grout In pe prior t grouti nd a final inspection. <br /> Signed X Title: Date: <br /> E (Draw Plot Plan on Reverse Side) <br /> R D ARTMEN USE ONLY <br /> PHASE 1 <br /> Application Accepted By Date—/-2 / 7,9' <br /> E Additional Comments: <br /> Phase It Grout Inspection Phase 111 Final Inspection <br /> Inspection By Date Inspection ByDate4h� � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE t; REMIT <br /> BASE EXPLANATION DATE MATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS our <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> -� <br /> Received by Date - Receipt No. Permit No. Issuance Date Mailed Delivered <br />