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Applications Will Be Processed When Submitted Properly Completed. Be Su SignTheApplication. C=� <br /> s F_ OFFICE USE: : APPLICATION 5 1980 <br /> (For Non-Transferable, Revocable, Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SAN <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> � G6f <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application ism <br /> made in compliance with San Joaquin County Ordinance N 1862 and the rules and regulations of the San,lOaquin Local Health District. 1"' <br /> Exact Site Address F � -ev °` City/Town f - <br /> . ff <br /> nPho <br /> 97Z <br /> Owner's Name & � Phone <br /> Address City <br /> Contractor's Name <br /> t (� � � License# Business ne 2a "" yl <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes �� No <br /> TYPE OF WORK (CHECK): NEW WELL I" DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATiONX PUMP REPAIR <br /> REPLACEMENT❑ e <br /> It <br /> i <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 I <br /> ❑ DISPOSAL ❑ OTHER Other Information (�l <br /> 1:1Y ICAL Surface Seal Installed By: <br /> GEOPH S <br /> PUMP INSTALLATION: Contractor e- v <br /> Type of Pump H.P. <br /> i <br /> PUMP REPLACEMENT: ErState Work ponewJVA <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter — A proximate 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 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/Grut inspection prior to grouting and a final inspection. <br /> Signed X � "lam Title: —_ .� R Date: / �. <br /> (Draw Plot Plan on Reverse Side) <br /> OR DEPARTMENT USE ONLY <br /> PHASE I Dat J <br /> Application Accepted B <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> inspection B.y ! Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER,UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By January 31 El July 1.&Received By July 31 <br /> I <br /> REMIT <br /> J.,f BILLING REMITTANCE $ <br /> AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> .� DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - I <br /> OTHER <br /> OTHER <br /> Received by +-+ Date Receipt No. Permit No, Issuance Date. Mailed Delivered <br /> !. at <br /> .. APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMIT/SERVICES .1601 E.HAZELTON AYE.;-P.O. x 2008 .STOCKTON,CA 95261 <br />