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Apprifi ct?tions Will Be Processed Wh nJubmitted Properly Completed.Be Sure o <br /> APPLICATION <br /> LrORFFICE USE: <br /> (For Non-Transferable, Revocable, Su1i pendable) PUMP&WELL <br /> SAV.4 joarQWN WAMONMENTAL HEALTH PERMIT <br /> WATER QUALITY, <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby ma de k1ye�In <br /> quin Local Healt�District for a permit to construct and/or install the work.herein described.This application is <br /> made in compliance with a Jhounty din c62 and th ru eg lations of the San Paquin Local Health D' tri <br /> Exact Site Address City/Town <br /> f <br /> _� Phone ' <br /> Owner's Name r <br /> " a _ City <br /> Address Business Phone <br /> Contractor's Name <br /> License# � - <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With Si HD? YesNo , <br /> TYPE OF WORK (CHECK): NEW"WELL❑� DEEPEN ❑ RECOND1T10N❑ "`I" DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP"i INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines PitePrivy <br /> Sewage Disposal Field Cesspool/seepage Pit Other <br /> Property Line Private Domestic Well 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 /> 11 IRRIGATION 11 GRAVEL PACK Depth of,Grout Seal 5 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout r. <br /> 11 DISPOSAL 11 OTHER Other Information <br /> F, - .Surface Seal Installed By: <br /> k r❑ GEOPHYSICAL ` <br /> PUMP INSTALLATION: Contractor <br /> Typ Pump H.P. <br /> PUMP REPLACEMENT: State Work Done 4 <br /> ❑ State Work Done <br /> PUMP REPAIR: `" roximate Depth <br /> DESTRUCTION OF WELL: Well Diameter App <br /> Describe Material and Procedure <br /> I hereby certify that I have prepared this application and that the work wljl be done ih?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 <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 for which this <br /> permit is iss d, I shall employ persons subject to workman's compensation laws of California." <br /> I will ca or a Grout Inspection prior to routing and a final inspection. 6. <br /> Date: <br /> Signed X <br /> (Draw Plot &Reverse Side) <br /> FOR DEPARTMENT USE,ONLY <br /> PHASE I Wim:. Date <br /> Application Accepted By <br /> Additional Comments: A <br /> Phase III Final Inspection <br /> Phase 11 Grout Inspection <br /> Inspection By <br /> Date inspection By ��`�' Date <br /> r Fee Is Due: 11 ANNUALLY C] PER UNIT ❑ PER SITE ❑ EACH' ❑ January 1 8 Received By January 31 ❑ July 1 &ReceiveRdERlyIT 31 <br /> i <br /> - BASE EXPLANATION t 611-LING -REMITTANCE '$ ty ~AMOUNT DUE CHECKER <br /> DATE DATE` REMITTED AMOUNT <br /> i. <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS � <br /> PENALTY - k <br /> k" <br /> OTHER <br /> OTHER <br /> Received by <br /> Date— Receipt No.- Permit No, ,y -- Is ante ate Mailed Delivered . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL 1iEALT14 PERMITISERYICES <br /> 4601 E.RAZELTON AVE.,P.D.ao■2009 STOCKTON,CA 95201 <br /> i <br />