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Applications Will Be Processed When Submitted Properly Completed. BeSureToSign TheAppucallon. y <br /> APPLICATION / 11 <br /> F_ORaOFFICE USE: ]/ I <br /> Cp 11 1 (For Non-Transferable, Revocable, Suspendable) /// <br /> PUMP&WALL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �i <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �1 <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.1862 and the rules and regulations of the San Joagtyn I Health District. <br /> Exact Site Address ! /f 4e City/Town <br /> AlOo Phone Il <br /> Owner's Name <br /> Address Q City 2,—74 7 4 <br /> Contractor's Name n.�r License# 7� � Business Phone <br /> Contractor's Address hl•� Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File WI SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ 00 <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> f <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> i ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> El DRILLED Dia. of Well,Casing I <br /> � DOMESTIC/PRIVATE II <br /> ❑ DOMESTIC/PUBLIC ❑ 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 Surface Seal [ ailed By: W <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump 1E <br /> m H.P. <br /> 1 PUMP REPLACEMENT: ❑ State Work Done <br /> M State Work Done getVia« <br /> PUMP REPAIR: <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of thework forwhich this permit <br /> f 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 /> 1 permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> is <br /> 1 I call for a Grout In ct' n p ' grouting d a final inspection. I <br /> //46/42 <br /> Signed <br /> Title: Dale: 6 <br /> (Draw P t Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> Application Accepted By I <br /> Additional Comments: <br /> Phase 11 Grout Inspection ip,Pl@ ISI al Inspection <br /> Inspection 8y Date Inspection By }I Date l' <br /> k Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January'l &Receive January 31 ❑ July 1 &ReceivedEMyl July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE .C] <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> is <br /> OTHER <br /> OTHER <br /> IDate Receipt No. Permit No Issuance.Date Mailed Delivered <br /> Received-by <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />