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Applications Will Be Processed When Submitted Properly Completed. Be Sure To tgfdn�hppl,oica#onto <br /> FOR OFFICE USE: APPLICATION / <br /> (For Non-Transferable, Revocable,Suspendable) Tiff�J� <br /> ENVIRONMENTAL HEALTH PERMIT {I vvv <br /> WATER QUALITY SAN JOS UIN LOCAL <br /> (COMPLETE IN TRIPLICATE) � `�-' <br /> Application is hereby made to the San Joaquin Local Health District for a ermittoc structand/or install the worerlit}�scfTpplication is <br /> made in compliance wi S aqn CoJar}tdinan a No 1862 the ru`ke e a ons of the San Jo in iLocal al I ri t. <br /> n <br /> Exact Site Address ((�� City/Town C> " <br /> Owner's Narn V� t! Phone <br /> Address City <br /> Contractor's Name �� License# 3�BLISIA ySS Phone ' <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJ LH D? Yes_ y No T Q <br /> TYPE OF WORK (CHECK): _ NEW WELL`❑ DEEPEN ❑ RECONDITION 11 DESTRUCTION❑ h <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 J_ 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 Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: State Work Don <br /> DESTRUCTION OF WELL: Well Diameter OAK <br /> dpproximate 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> is issued, I shall n mploy any person in such manner as to become subjec to workman's compensation laws of California." <br /> Contractor's h' g or sub-contracting signature certif lei the following:"I y that in the performance of the work forwhich this <br /> per Is iss d, I shall mploy sons subject to workman's comp sa ' n laws of California." <br /> I ill a a t spectio rior t r in nd a final inspecti . � 13;�J__ <br /> Signed X Tltle: Date: <br /> (Draw Plot Plan o everse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I � Date <br /> Application Accepted By lit <br /> Additional Comments: 1 <br /> Phase 11 Grout Inspection Phase III Final Inspection <br /> Inspection By o Date Inspection By- Date <br /> s � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1.&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING EMITTANCE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 1 <br /> OTHER <br /> Receipt No. Permit No. '� Isjuance[Pate Mailed Delivered� <br /> PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Sox 2009 STOCKTON,CA 95201 _ <br />