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Applications Will Be Processed When Submitte roper <br /> =(ICOMPLETEE <br /> USE: ly <br /> APPLICATION II�� � � <br /> (For Non-Transferable, Revocable,Suspendable�l�R <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PER��T� Fipr.Q ;lti LOCAL <br /> WATER QUALITY q-{�j�,LTH DISTRICTATE) <br /> Application is hereby madetotheSanJoaquinLO��inancehlVo51862andict for a phe rules and regulaDnsoftthe San JkaquinlLocal Healibedt TDisthis ap{plicationls <br /> made in compliance with San Joaquin aunty City/Town <br /> Exact Site Address / t <br /> Phone <br /> Owner's Name /"TSI <br /> City <br /> Address ,n / '' r7 Bu iness Phone r w <br /> Contractor's Name v License#s q ` r, <br /> 4 If - Emergency Phone _V_ <br /> Contractor's Address � No <br /> ESTRU <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? ;Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECO[ISI P MP IND ALLAT ONOTIO❑ PUMP REPAIR© <br />` WELL CHLORINATI ❑ WELL ABANDONMENT ❑ OTHER , <br /> i <br /> REPLACEMENT Sewer Lines <br /> ` Pit Privy <br /> F - DISTANCE TO NEAREST: Septic Tank <br /> Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Well •.. <br /> INTENDED USE TYPE OF WELL <br /> ❑�. <br /> D USTRIAL 11 CABLE TOOL Dia. of Well Excavation <br /> ,�, 11 DRILLED Dia. of Well Casing l� DOMESTIC/PRIVATE ❑ DRIVEN Gauge of Casing <br /> ❑ <br /> DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout <br /> C1 CATHODIC PROTECTION ❑ ROTARY <br /> 11 DISPOSAL ❑ OTHER Other Information <br /> Surface Seal installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION: Contractor H.P. <br /> PUMP REPLACEMENT: State Work Done <br /> PUMP REPAIR: ❑ State Work Done Approximate DeptJill <br /> h <br /> . . DESTRUCTION OF WELL: Well Diameter <br /> Describe Material and Procedure <br /> �. <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 <br /> C: 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 iorwhich this <br /> {k permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> f I will r a Grout In ection prior to grouting and a final inspection. <br /> ' Title: _ C/Li�^� 1� Date: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I Date <br /> s Application Accepted By <br /> Additional Comments: ase 11 Final Inspection <br /> ( Phase ll Grout Inspection G�1 pate <br /> Inspection By <br /> Date Inspection By <br /> ❑ EACH ❑ January 1 &Received By-January 31 ❑ July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE REMIT <br /> l BILLING REM4TTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE `•S .-. - <br /> LESS <br /> PRORATION <br /> PLUS <br /> k. PENALTY <br /> OTHER <br /> t OTHER - a` 7 � <br /> ' rPermi No. issuance Date Mailed Delivered <br /> Date Receipt No. <br /> Recelved by 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br /> -APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERM <br /> I775ERVICES 3 ' <br />