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Applications Will Be Processed When Submittedr x <br /> APPLICATION <br /> FOR OFFICE USE: I (For Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> I � <br /> ENVIRONMENTAL HEALTH PERMIT <br /> IM I WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ! ' Ilthework <br /> Application, cp <br /> ,! Joaquin Local Health District for apere rules and regulations oftthe San Joaquinitocal Health TDisthis application is <br /> ii Q <br /> made in compliance with San Joaquin County Ordinance Na.1882 and City/Town <br /> Exact Site Address <br /> I`� ' Phone <br /> Owner's NA e .�I City <br /> Address �� /usiness Phone �'�` �T - <br /> License#��?L 1 <br /> Contractor�I Name Emergency Phone 1 <br /> CI -5 1 <br /> Contractorls Address No <br /> 41; <br /> is Certificate of Workman's Compensation Insurance on File With SJLHD? es <br /> TYPE OF WORK (CHEGK): NEW WELL DlEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> PUMP REPAIR❑ <br /> WELL CH ii.LORINATION ❑ WELL ABANDONMENT ❑ OTHER 13PUMP IN i <br /> REPLACEMENT❑ , Pit Privy <br /> Sewer Lines <br /> DISTANCE TO NEAREST: Septic Tank essp <br /> Cool/Seepage Pit Other <br /> Sewage Di <br /> Il: sposal Field Public domestic Well <br /> Property Line Private Domestic Well—_.�� <br /> INTENDED USE TYPE OF WELL <br /> l cavation <br /> Ill: Dia. of ., <br /> 11 INDUSTRIAL 11 CABLE TOOL y r <br /> Dia. Well Casing <br /> 13 DRILLED a. og <br /> DOMESTIC/PRIVATE <br /> 11 DRIVEN Gauge of Casing <br /> 11 DOMESTIC/PUBLIC Depth of Grout Seal <br /> ❑ IRRIGATION I 11 GRAVEL PACK N <br /> 13 ROTARY Type of Grout h} <br /> llCATH1�DIC PROTECTION <br /> 11 OTHER ! Other Information <br /> 13 DISPOSAL Surface Seal Installed By` <br /> -1 GEOPHYSICAL # <br /> k PUMP INSTALLATION: Contractor # H P Q <br /> Type of Pum f <br /> I ' C3 State Wor on <br /> PUMP REPLACEMENT- � <br /> y► ❑ State Work Done { - <br /> # PUMP REPAIR: F Approximate Depth <br /> p - '""We11 Diameter j <br /> DESTRUCTION OF WELL: I <br /> Describe Material and Procedure <br /> ✓ ' <br /> I hereby certify that (::have prepared this application and that the work will be done <br /> accordance with San Joaquin County , <br /> ordinances, state laws, and rules and regulatibhs of the San Joaquin Local Health District. y <br /> i ! signag. <br /> Home owner aalllnot;m loynany person in sudh mannerlas to become subject to workm nos compensationnce of the work f aws of Cal foorwhich this En alt 5 <br /> j is issued, 1 sh P <br /> i Contractor's hiring o41, <br /> sub-contracting signature certifies the following:"I certify that i.nthe performance of the work forwhich this <br /> I ' permit is issued, 1 shall employ persons subject to workman's compensation Iaws`of California." <br /> L1I will c r a Grout Inspection prior to grodting and a final inspection.* <br /> ff I <br /> Ih I Title: a Date: <br /> Signed'+ j I <br /> (Draw Plat Plan on Reverse�Side) } <br /> t I FOR DEPARTMENT USE ONLY <br /> k HASE I Date <br /> _ =k <br /> Application Accepted By.;' E <br /> Additional Comments: Phase Ill Fi a eclion <br /> Phase it Grout Inspection to <br /> I ` <br /> Date inspection B <br /> i Inspection By i� j <br /> - i , <br /> Fee Is Due: ❑ ANNUALLYi. ❑ PER UNIT 1WPER SITE ❑ EACH ❑ January 1 &Received By Sanuary 3t ❑ July 1 &ReceiveRd REMIT 31 <br /> REMITTANCE s AMOUNT DUE CHECKED <br /> BASE EXPLANATION BILLING DATE <br /> I {REMITTFD AMOUNT <br /> FEE <br /> X15 <br /> LESS t <br /> PRORATION .I - <br /> t i PLUS <br /> PENALTY <br /> I II: OTHER <br /> i <br /> 11 <br /> OTHER <br /> t ' <br /> I II' Permit No. Issuance Date Mailed De vered <br /> Received by !IlDate Receipt No. r <br /> 44 ifi01 E.HAZELTON AVE.,P.O•Box 2005 STOCKTON, <br /> t ° I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - <br />