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.AppitcattonsWill Be Processed When Submitted Properly Completed � �he Applfcatflxlr� <br /> FOR o1=iE USE: APPLICATION !:.' �g�0 <br /> (For. Non-Transferable, Revocable,Suspen A� <br /> H PIP,&WELL <br /> ENVIRONMENTAL HEALTH PERMIT t,� <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY S� r p� � DtS- R rl <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install +IGi �N <br /> herein described.This applicatio is <br /> made in compliance wih15an va i�0Unyy }'d_in nce No. 1 a the ru s and regulations of the Sa Joa Lin oc��ealth District. <br /> Exact Site Address /® 7 .�O City/Yawn <br /> /h $ <br /> Owner's Name L)7V�� ) <br /> .11132 <br /> /I Phone 11�1O �` �77 <br /> Address Q� <br /> Contractor's Name >�s- /9 J✓J S 7 City I <br /> icense# Business Phone <br /> Contractor's Address L s,>77 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRO� I <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field # Cesspool/Seepage Pit=L, • 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 <br /> ❑ DISPOSAL ❑ OTHERt <br /> Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: pj <br /> PUMP INSTALLATION: Contractor <br /> ..D <br /> Type of Pump H,P. .� <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: 01-6tate Work Done r � <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 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. 1 <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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's h' ' r sub-contracting signature certifies the following"I certify that in the performance of the work forwhich this <br /> permit' d, I shall employ pe subject to workman's compen on laws of California." <br /> I a u nspectio prior to grouting and a final inspec n. <br /> Signed X - Title. Date; <br /> (Draw Plot Plan on Reverse Side) <br /> DE ARTMENT USE ONLY <br /> PHASE p <br /> Application Accepted By Date 02 O <br /> Additional Comments: <br /> Phase Il Grout Inspection P a I anal Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT IPPER SITE ❑ EACH ❑ January 1 &Received By January 31r <br /> 1:1 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE E}CPLANATlQN AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER - -� <br /> ISO B <br /> Received by Date Receipt No Permit No. IsEftiance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.flax 2009 STOCKTON,CA 952 <br />