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Applications Will Be Processed When Submitted Properly Comp e e . <br /> k APPLICATION <br /> =(COMPLETEN <br /> OFFICE (For Non-Transferable, Revocable,Suspendable} PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY Ilcation is <br /> ATE} struct <br /> Application is hereby madetotheSanJoaquinLocdinancehNost1862�r dPhe ides and regulations oftthe San Joa uinlL cal Health District. <br /> made in compliance with San Joa U In . ouP Y O City/Town J <br /> Exact Site Address phone <br /> �. <br /> .: <br /> Owner's Name City <br /> Address License# Business,Phone ,. e <br /> Contractor's Name Emergency Phone 'S <br /> Contractor's Address No <br /> Is Certificate of Workman's Uompensa ion Insurance on File SR GON4ITION DESTRUCTION❑ <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN <br /> PUMP INSTALLATION PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 13 -OTHER <br /> ❑ l� 111 ry <br /> REPLACEMENT El Pit Privy ~ <br /> DISTANCE TO NEAREST: Septic Tank ; Sewer Lines Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property,Line Private Domestic Well <br /> INTENDED USE . TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL Dia. of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> DOMESTIC/PUBLIC [] GRAVEL PACK Depth of Grout Seal E <br /> ❑ IRRIGATION 13 ROTARY Type of Grout `? <br /> ❑ CATHODIC PROTECTION 11 OTHER Other information <br /> 11 DISPOSAL Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> Contractor H P <br /> i PUMP INSTALLATION: Type of Pump <br /> I State Work Done <br /> PUMP REPLACEMENT: © State Work Done <br /> ' PUMP REPAIR: Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter <br /> + Describe Material and Procedure-. <br /> I hereby certify that I have prepared nd rein application <br /> the San Joahqu noLocalrk llHealtth District be done in accordance with San Joaquin County <br /> j ordinances, state laws, and I certify that in the performance of the work for which this permit <br /> ies the following: <br /> Horne owner or licensed agent's signature certifies " Y <br /> is issued, I shall not employ any person in such manner as to become subject to workman's comensation laws of California." <br /> p <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify-chat in the performance of the work forwhich this <br /> permit is issued, I shah employ persons subject to workman's compensation laws of California." <br /> ' <br /> I I will call for a Grou Inspection prior to grouting and a final inspects <br /> Title: <br /> Signed X- _ r (prow Plot Plan on Reverse Side) <br /> t i FOR DEPARTMENT USE ONLY <br /> Date <br /> PHASE <br /> Application Accepted By <br /> Additional Comments: ha I inal Inspection <br /> ' Phase If Grout Inspection Date ! <br /> inspection By <br /> Date Inspection By <br /> REMIT <br /> Fee is Due: E3 ANNUALLY <br /> [3 PE UNIT'' ❑ PER SITE El EACH ❑ January 1 &Received BY January 31 ❑ Ju4y 1 &FleceiC�ECKEQBy y 3t <br /> BILLING REMITTANCE $ AMOUNT OUE AMOUNT <br /> BASE' EXPLANATION DATE DATE REMITTED <br /> FEE <br /> 't <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> t� sled Delivered J <br /> Date Receipt-No. <br /> Permit No. Issuance Date <br /> Received by 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />