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'Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> FOR oFFlce use: APPLICATION <br /> - (For Non-Transferable, Revocable, Suspendable) r <br /> y WUMP&WELL <br /> N. WATER <br /> ONMENTAL HEALTH P <br /> (COMPLETE IN TRIPLICAT�>�S.�� WATER QUALITY CA 5z�d <br /> Application is hereby.mad an oaq oca Istrictfor apermit toconst ructa �/or install thewo herein descrtbed.This-application is <br /> made in compliance With San Joaquin Cipun,ty Ordinanc_9 No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address r 9F City/Town <br /> Owner's Name Phone <br /> Address City <br /> Contractor's Name - License# Business Phone! <br /> Contractor's Address ,Emergency Phone <br /> Is Certificate of Workman's Compensation Insuran on File th SJLHD? -Yes <br /> No + <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN RECONDITION El DESTRUCTION❑ r, <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT 11 — ,__ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TAPE OF WELL <br /> ❑ iN�STRIAL CABLE TOOL Dia. of Well Excavation – <br /> LFrDOMESTIC/PRIVATE ❑ DRILLED pia. 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 Surfa Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H• <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ~, r ❑ State Work Done <br /> n <br /> r DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure + <br /> I 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 <br /> E 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 empl y persons subject to workman's compensation laws of California" <br /> I will.01 for a Grout Inspe ion prior to grouting and a final inspec' n. <br /> Signed X Title: <br /> f ,� Date: <br /> (Draw Plot Plan on Reverse Side) <br /> y� II <br /> per- 1' s FOR DEPARTMENT USE ONLY <br /> PHASEI j <br /> Application Accepted By d Date 7� <br /> 2A�C i <br /> Additional Comments: 'i <br /> hase I al Inspection ���� ' <br /> �ell ut Inspection„ 1 <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE EACH ❑ January 1 &Received By January 31 El July 1 &Re ed By July 31 r <br /> REMIT <br /> i- BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> b � O <br /> FEE <br /> l LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuancd Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITI$ERVICES r 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />