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Applications Will Be Processed When Submitted Properly Completed B !\ZASignt7Th%Apph'dation.I �� <br /> FOR-OF.FICE USE: APPLICATIONCj[` <br /> (For Non Transieragle, Revocable,Suspendabl <br /> ENVIRONMENTAL HEALTH PERMIT P� �Yey\ &WELL <br /> ' <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S ��� �. <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install thework.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 City/Town +� <br /> Owner's NameAl <br /> Phone X273 -27�7 <br /> d <br /> Address 17 '1 City } <br /> Contractor's Name License# kOok Business Phone <br /> 7 i <br /> Contractor's Address Emergency Y Phone <br /> Is Certificate of Workman's Compensation Iurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELIMP DEEPEN ❑ RECONDITION❑ DESTRUCTION <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 11OTHER ❑ 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 /> 0 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information a� <br /> ❑ GEOPHYSICAL � lf Surface Seal Ins ailed By: <br /> PUMP INSTALLATION: Contractor 44 <br /> Type of Pump H.P. E <br /> PUMP REPLACEMENT: State Work Done ­,'Rz 1-� 4 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth 917; <br /> Describe Material and Procedure . <br /> j <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 for which this <br /> permit is issued, 1 shall employ persons subject to workman's compensation laws of California." P�A, <br /> 04 <br /> I will call for out Inspection prior to grouting and a final inspecti . f <br /> Signed )( _/ --�`� Title: Date: <br /> (Draw Plot Plan on Rev rse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By. Z!3 Date 3 <br /> Additional Comments: V i _ - ~ <br /> Phase II Grout InspectionP se III Final Inspection <br /> Inspection By Date Inspection By Date Z� <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 e 1, By Ju)ji 31 i <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS y <br /> PENALTY <br /> OTHER <br /> I, <br /> OTHER <br /> Received by Date ii Receipt No Permit Issuance Date Mailed Delivered- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E:HAZELTON AVE.,P.O.Box 2009 STOCKY..,CA 9520 ' <br />