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u. <br /> Applications Will Be Processed When Submitted Properl <br /> APPLICATION; <br /> FOR OFFICE USE, (For Non-Transferable,Reracable;suspendable) PUMP&WELL <br /> •• <br /> -_ ENVIRONMENTAL IKEALTH PERMIT „ n $ / <br /> WATER QUALITY r 'v( 1 <br /> (COMPLETE IN,TRIPLICATE) <br /> allthewor <br /> Application is hereby made to the San Joaquin Local Health Distr80. a a Pee rules and regulations oftthe San Joaquin LocalCHeathTDistrcplication is <br /> made in compliance with San Joaquin Court, Ordinance No.18 and t City/Town <br /> Exact Site Address Phone v <br /> Owner's Name ` -:,' City <br /> Address '- a License# 7 k 7�5' Business Phone <br /> Contractor's Name �, Emergency•Phorie y <br /> No <br /> Contractor's Address _ _ - - <br /> Is Certificate of Workman's Compensation insurance on File With SR CONDITION 0 DESTRUCTION❑. ❑ <br /> TYPE OF WORK (CHECK): NEW WELL�� DEEPEN <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ®� PUMP REPAIR <br /> REPLACEMENT❑ Pit Privy <br /> f Sewer Lines Z�� <br /> DISTANCE TO NEAREST: Septic Tank j� Q�:— Cesspool/See page Pit Ems — Other _ <br /> Sewage Disposal Field <br /> Property tine�Private Domestic Well_ ell <br /> Public Domestic W <br /> TYPE OF WELL <br /> INTENDED USE Dia. of Well Excavation <br /> ❑ INDUSTRIAL ❑ CABLE TOOL <br /> ,�.,� Dia. of Well Casing <br /> La DOMESTIC/PRIVATE ❑1 DRILLED DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLICDepth of Grout Seal <br /> ❑ IRRIGATION C!�GRAVEL PACK d <br /> I QROTARY Type of Grout <br /> El CATHODIC PROTECTION OTHER Other information 6 [� <br /> [3 DISPOSAL Surface Seat installed B <br /> ❑ GEOPHYSICAL <br /> Contractor }{p <br /> PUMP INSTALLATION: <br /> Type of Pump � <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ElState Work Done <br /> PUMP REPAIR: Approximate Depth <br /> Well Diameter <br /> DESTRUCTION OF WELL: <br /> Describe Material and Procedure <br /> I hereby certify that have prepared this application and he SanttheJoaquin work <br /> willbe al Healdone in District cordance with San JoaJCcwn <br /> ordinances, state laws, and rules and regulations <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhiis issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws o <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify,that in the performance of the work <br /> ns subject to workman's compensation laws of California." <br /> permit is issued, i shall employ perso <br /> 1 will call for Grout Inspection prior to grouting and a final inspection./S t Date: <br /> Title: <br /> Signed X (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY �] <br /> FFee <br /> Ir C' Date +_ <br /> on Accepted By <br /> l Comments: phase 111 Final inspection <br /> Phase 11 Grout Inspection Date ? �� <br /> ection B ' <br /> Date inspection By <br /> UB: ❑ ANNUALLY PER UNIT; ❑ PER SITE El January 1 &Received By January 31 ❑ July i &Received <br /> RE By 31 <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> v <br /> OTHER <br /> Yss� e Date Mailed Delivered <br /> it N <br /> Receipt Permit No. <br /> Received by � � Date 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICFS <br />