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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 'OFFidE USE: APPLICATION (� <br /> (For Non-Transferable, Revocable,Suspendable) �' U <br /> P& LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY I <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Co�urmt Ordin nce No. 1862 and the r s and l tions of the San Joa ui h Local Heal District. <br /> Exact Site Address i. ., � '! ` �'{ ruCity/Town `rg <br /> Owner's Name Phone <br /> Address City f <br /> Contractor's Name ` License 4&.2,7 3 Business Phone <br /> Contractor's Addressr Emergency Phone �_� f <br /> Is Certificate of Workman's Compensation Insurance onile With SJLHD? Yes .4�. No <br /> TYPE OF WORK (CHECK): NEW WELL Fir DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION 1;1' PUMP REPAIR❑ �- <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank J o Sewer Lines Pit Privy + <br /> Sewage Disposal Field Cesspool/Seepage Pit Other E <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation `s <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ep <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION GRAVEL PACK Depth of Grout Seal l <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surfaceeal Installed By- <br /> PUMP INSTALLATION; Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work"Done I <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 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 /> 1 <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich 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 gall for a Grout Inspection prigitomgrouting and a final inspection. " <br /> � 4 7�Signed X Title: Date: <br /> l {Draw Plot Plan on Reverse Sid <br /> ✓ FOR D71b <br /> TMENT USE ONLY <br /> PHASE <br /> Application Accepted By ��' "'°' ✓ Date ' <br /> Additional Comments:- <br /> Phase <br /> omments:Phase 11 Grout Inspection Phase III Final Inspection { <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ' <br /> DATE DATE REMITTED _ <br /> AMOUNT <br /> FEELESS <br /> t_ ✓ `I f_3 <br /> a <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER f <br /> f <br /> ER <br /> 2 4-2/-3 ? 9-?q5 /.;� <br /> Receiv d by Dae Receipt No. Permit o- Issua a Date Mailed Delivered <br /> APPLICAN —PWTURNALL-COPIES TO:' •ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />