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Applications Will Be Processed When Submitted Properly Completed �N Ir T�_ S� e� <br /> FOR OFFICE USE: APPLICATION w pp d <br /> r.w I (Fpr Non-Transferable, Revocable,Susp we) <br /> ENVIRONMENTAL HEALTH PERMIT FFEB 2 9PW& <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY ��� <br /> Application is hereby made to the San Joaquin Local Health District fora permit toconstruct and/ori "�' e k <br /> made in compliance wit n a Cou pr�inance No. 1862 and 4he rut regulations of the Sa� jDt WMibed..�This applica ion is <br /> Exact Site Address �j��✓ � L* City/Town �oe �/ <br /> Owner's Nam <br /> Address Phone <br /> ALL o: <br /> Contractor's Name �� ""` Ut�9 City <br /> *jQense <br /> Bus ne�s�ho <br /> Contractor's Address Emergency Phone rw <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD?',/Ves I <br /> No <br /> TYPE OF WORK-(CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑�_' DESTRUCTiON❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ ;PUMP=INSTALLATION ❑ PUMP REPAIRC <br /> REPLACEMENT❑ i <br /> DISTANCE TO NEAREST: Septic Tank Sewer-Lines ' 4� <br /> reit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit+ ` Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL I <br /> I USTRIAL- •❑ CABL£TOOL Dia of Well Excavation <br /> ❑ D MESTIC/PRIVATE D DRILLED <br /> Dia. of Well Casing <br /> ❑ D R GATIION UBLIC � DRIVEN Gauge of Casing <br /> ❑ GRAVEL-PACK---- a._- t,,(Depth Of-Grout-Seal-- a <br /> CATHODIC PROTECTION ❑ ROTARt Type of Grout <br /> ❑ DISPOSAL ❑ OTHER <br /> ❑ GEOPHYSICAL Other Information <br /> SuIiface Seal Installed By: <br /> PUMP INSTALLATION: Contractor 1 <br /> Type of Pump t H.P. <br /> J <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: t� El State Work Done ' <br /> I <br /> DESTRUCTION OF WELL: Well Diameter p <br /> Approximate 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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit 1 <br /> is issued, I shall employ any person in such manner as to become s ctto workman's compensation laws of California." <br /> Contractor's Ing or sub-co ng signature certifies the following; I rtify that in the performance of the work for which this I <br /> p mit is I ed, I sha I emp oy per ns subject to workman's compe ation laws of California." <br /> I will r fnspec 'on pri t rou , g and afinal i o . <br /> Signed X Titl <br /> t Date: <br /> (Draw Plot Plan n Reverse Side) <br /> PHASE I FOR DEPARTMENT USE ONLY <br /> Application Accepted By 97111 Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By } Date Inspection By Date <br /> Fee IS Due: ❑ ANNUALLY PER UNIT ❑ PER SI E ❑ EACH'. ❑ January 1`&Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT } <br /> 1 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> Y <br /> FEE AMOUNT <br /> /7 j - , <br /> LESS a <br /> PRORATION - <br /> PLUS [ <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> , E <br /> Received 5y Date <br /> Receipt No. - -. Permit,N". I Issuaniab Date Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009. STOCKTON,CA 95201 <br />