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-{ __Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION _ <br /> (For Non-Transferable, Revocable,Suspendable) <br /> - ENVIRONMENTAL HEALTH PERMIT PUMP&WALL r j <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY �1 <br /> Application is hereby made to the San Joaquin Local Health Districtfora permitto construct and/or install thework herein described-This application is ' r <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San oaquin Local Health District. <br /> ExactSite Address Zen City/Town 4 C_ ,4.40/0 C <br /> Owner's Name O O Phone <br /> Address ' 1Q0 City A; <br /> Contractor's Name �7 'l1 License #6279k�)JC2Business Phone 91&&-z20,7 <br /> I <br /> Contractor's Address J/?) Emergency Phone ,ox <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 REPAIR <br /> REPLACEMENTS _ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well 1 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 ❑ OTHER Other Information +.- <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �y <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: IN State Work Done C YYVa Cl t ;M- �7- �_ /J✓�;542— <br /> PUMP <br /> 5fPUMP REPAIR: ❑ State Work Done . r <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit r <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 /> ;:t <br /> I will a_II for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title:— Date: 5>—z�_-- <br /> (Draw Plot Plan on Reverse Side) <br /> FOR D ARTMEN USE ONLY <br /> PHASE I r7 <br /> Application Accepted By bate <br /> Additional Comments: <br /> Phase II Grout Inspection Ph I f=inal In ection <br /> Inspection By Date Inspection ByQT, D —Z —� <br /> Fee is Due: El ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 - ❑ J &Received By July$t <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> PATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION S <br /> PLUS <br /> PENALTY <br /> OTHER <br />!' OTHERJ21 V26% 1� <br /> Z) r, <br /> Received by bale LReceipt No. Permit No. Issuance Date Mail d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,'P.O.Bax 2009 STOCKTON,CA 95201' <br />