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��. .. <br /> F Applications Will Be Processed When Submitted Properly Completed. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable, Suspendable) pUMP &WELL <br /> k <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <br /> Joaqui n Local Health Districtfora a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San <br /> made in compliance with Sa � .0 unty O ante No. 62 ,he rules and regulations of the San Joa uin Local Health District. <br /> City/Town <br /> Exact Site Address <br /> Phon <br /> Owner's Name City <br /> Address I <br /> Contractor's Name License#i 737 'l Q BIn ss P1�on <br /> Contractor's Address + Emergency Phone <br /> y ) <br /> � Is Certificate of Workman's Compensation Insurance an File With 5JLHD7 Yes No <br /> TYPE OF WORK (CHECK): NEW WELL IJ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> I WELL CHLORINATION 11 WELL ABANDONMENT C3OTHER ❑ PUMf INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑ { <br /> Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> 1 Sewage Disposal Field <br /> I Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> 13 INDUSTRIAL El CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ <br /> Gauge of Casing <br /> DOMESTIC/PUBLIC 11 DRIVEN <br /> r ❑ IRRIGATION 11 GRAVEL PACK Depth Grout Seal <br /> 13 CATHODIC PROTECTION ElIfnformation <br /> ROTARY Type Grout <br /> ❑ DISPOSAL ❑ OTHER <br /> { b - Other Surface Seal Installed By: <br /> C1 GEOPHYSICAL F <br /> PUMP INSTALLATION: Contractor <br /> s t H.P. <br /> Type of Pump _ - <br /> PUMP REPLACEMENT: ❑ State Work Done w <br /> PUMP REPAIR: State Work Done <br /> t DESTRUCTION OF WELL: <br /> Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I <br /> I hereby certify that I have prepared this application tion and that the,work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ave pules and regulations of the San Joaquin Local Health District. <br /> f nce of the forwh <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performaof California." <br /> this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of <br /> k <br /> tify that Contractor's hiring or sub-contracting signature certifies the following:"1 cerf California." <br /> the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of <br /> 1 will call fora Grout Inspection for to grouting and a final -inspection. <br /> � Title: Date: <br /> i Signed X <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �J� - Date <br /> Application Accepted By 7 <br /> Additional Comments: <br /> tase III Fin spection <br /> Phase II Grout Inspection c bate <br /> Inspection By <br /> Date Inspection B <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By JT Jly 31 <br /> REMII BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> RASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> � o . <br /> FEE S <br /> 'r <br /> 4 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> d. ,o-� - <br /> � <br /> ' Received by Date , Receipt No, <br /> Permit No, ssuance ate Mailed Delivered <br /> —RETURN ALLCOPIESTO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT <br />