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Applications Will Be Processed When SubAmPPLICATION <br /> f PUMP&WELL <br /> FOR OFFICE USE' (For Non-Translerable, Revocable,Suspendable) [/ <br /> ENVIRONMENTAL HEALTH PER <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE} Ith District. <br /> made to the San Joaquin Local HealthDistrictforapfie rules andrregulations oftthe San Jo all the work he in Loc rein sl ribed.Thls <br /> Appiicafion is hereby City/Town �\ <br /> made in compliance with S I Joaquin Count ,Ordinance No.1862 an vV <br /> Exact Site Addres Phone <br /> Owner's N e -y <br /> Address License 4-* Business Business Phone <br /> Contractor's Name Emergency Phone <br />• � Yes� No <br /> Contractor's Address <br /> ❑ RECONDITION❑ DESTRUCTION1 <br /> Is Certificate of Workman's Compensation insurance DEEPEN With SJLH ❑ PUMP REPAIR❑ <br /> TYPE OF WORK (CHECK): NEW WELL <br /> WELL CHLORINATION ❑ WELL-ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION <br /> 13 Sewer Pnvy <br /> REPLACEMENT <br /> Sewer Lines Other <br /> DISTANCE TO NEAREST: Septic Tank cesspool/Seepage Pit <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line—Private Domestic Well <br /> INTENDED USE TYPE OF WELL.❑ CABLE TOOL Dia.of Well Excavation <br /> ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> i ❑ DOMESTIC/PR1vATE ❑ DRIVEN Gauge of Casing <br /> _DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> / {J IRRIGATION ❑ ROTARY Type of Grout <br /> ❑ CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Su face Seal Installed By: <br /> ❑ GEOPHYSICAL' r <br /> Contractor H.P. <br /> PUMP INSTALLATION: Type of Pump <br /> ❑ State Work Done <br /> PUMP REPLACEMENT: ❑ State Work Doneroximate Depth <br /> PUMP REPAIR: APP <br /> Well Diameter <br /> DESTRUCTION OF WELL: , <br /> Describe Material and Procedure - <br /> have prepared this application and that the work will be He d District.inaccordance with San Joaquin County <br /> I hereby certify that I ha p P <br /> l certif that in the performance of the work for sof California."ipermit 01 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local <br /> Home owner or licensed agent's signature certifies the following:" certifyct to <br /> that <br /> issued, I shall not employ ubje <br /> any person in such manner as tbecome <br /> me1l certify than intheperformance ofltheon lwork for wh ch this r <br /> c Contractor's hiring or sub-contracting signaljecuret <br /> certifies the following: <br /> permit is issued, I shall employ Persons subject to workman's compensation laws of California." <br /> ill c fora out Ins a <br /> lop for to grou' g and a Date: <br /> final inspect' n. ae� <br /> Tit! <br /> Sign d (Draw Plot Plan on everse Side) <br /> FOR DEPARTMENT USE ONLY �O46 <br /> w p� <br /> PHASE I �./ .f5.–�� Date —Q <br /> Application Accepted By <br /> Additional Comments: ase Ill Final Insp ction <br /> Phase 11 Grout Inspection Final <br /> Date Inspection By '' <br /> inspection By ❑ July 1 s Received By July 31 <br /> ❑ EACH C1Sanuary 1 &Received By January REMIT <br /> PER UNIT ❑ PER SITE CHECKED <br /> Fee IS Due: ❑ ANNUALLY C) PER <br /> REMITTANCE � AMOUNT DUE AMOUNT <br /> DATE <br /> T DATE REMITTED <br /> BASE t. EXPLANATION p <br /> FEE 4b <br /> LESS <br /> PRORATION <br /> PWS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Mailed Delivered <br /> Permit No. l uance ate <br /> Received by <br /> Date Receipt No. 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICE <br />