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' r ... ..,a,. I�Iw <br /> [FOR OFFICE USE: APPLICATION(Fpr Non <br /> �."- a -Transferable, Revocable, Suspendable} <br /> W�---"---------_.- -a ENVIRONMENTAL HEALTH PERMIT PWAP& WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or instal!the work herein described.This application is <br /> made in compliance with San Joaquin County 0dn ce No. 1862 end the rule a)fd regulations of the San Joaquin ocal HQalth District. <br /> Exact Site Address "� ;l _1/r __r ! //� City/Town <br /> Owner's Name '(- r!.%l- r.'-r.r Phone <br /> Address _ A � - <br /> r a7 r -9 y, _ City — f; I C) <br /> Contractor's Name jJ---l� ri •t%�- u�Y / VI #_ ._ • , +- ---�� 1 <br /> Lr._ �_• _,��.��''1 > .. .. __',, -�F usiness Phone d � �' <br /> Contractor's Address I i Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes _ No <br /> TYPE OF WORK (CHECK): NEW WEE;L ElDEEPEN 11RECONDITION C1 � DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER E❑ PUMP INSTALLATION�, PUMP REPAIR <br /> REPLACEMENT❑ I� 1 <br /> DISTANCE TO NEAREST: Septic Tank �7� r \ <br /> p , Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit 4 Other 1 <br /> Property Line ,7�W�� . Private Domestic Well R.,� Public Domestic Well -^-- <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> - --n-� <br /> �,DOMESTIC/PRIVATE ❑ DRILLED' Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC Q.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 — �� — <br /> Surface Sea Installed By: <br /> PUMP INSTALLATION: Contractor I,� '`' <br /> Type of Pump <br /> H.P. f <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done r -~ �� <br /> DESTRUCTION OF WELL: T <br /> Well Diameter. .. ..__ Approximate Depth <br /> Describe Material and Procedure <br /> I herebycertify that 1 have prepared this application and that the work will be done in accordance with San Joaqu'n County � <br /> ordinan6es, state laws, and rules and regulations of the San Joaquin Local Health District. rv 1 <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit LJ I <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 subcontracting 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 /> 01 tmalnsp lion Prior 4o growling and a final Inspection. <br /> r <br /> Signed X Title: r� 1"- Date . ' <br /> -- �� C3 <br /> (Draw Plot Plan on Reverse Side) <br /> I FOR DEPARTMENT USE ONLY 91 ® G✓ ,4 <br /> PHASE I �i �J`� > <br /> Application Accepted By f _ Q J Dat, l <br /> Additional Comments: <br /> II <br /> r <br /> Phase 11 Grout InspectionInspection ` <br /> Inspection By__�__� - Date _ Inspection By _ Datef.3 <br /> I ' <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Jani,ar <br /> _ T-. Y 1 &norckved By January 31 ❑ July 1 &Ree6vod By July 31 1 <br /> BASE I EXPLANATION BILLING 11EM111ANCf; S - REMIT �"- <br /> 1 OATE DAIL REMITTED AMOUNT our CHECKED <br /> AMOUNT <br /> FEE 1 C I nv — - L C'LESS <br /> - <br /> PRORATION !� <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No Issuance Date Mailed :v. <br /> Delivered <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 65201^I <br />