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r. - , <br /> Applications Will Be Processed Wfren Submitted Property Completed. <br /> APPLICATION <br /> FOR OFFICE USE: (for Non-Transferable,Revocable,Suspendable) PUMP&WELL <br /> } ENVIRONMENTAL HEALTH PERMIT !!! <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) or a p - Ilcation is <br /> Application is hereby madetothe San JoaquinLoCad`ae�alehfDostrifi2a dthe ule5ond regulationsofttheSan JoaquinLocal Health TDistrriictt.. <br /> made in compliance with Sa��aqu �in County O City/Town <br /> Exact Site Address <br /> Phone <br /> Owner's Name City _ <br /> Address rt f'. Business Phone. <br /> •+'t License#`� . , <br /> Contractor's Name P, <br /> n rt , tc, 'Emergency,Phone'' <br /> Contractor's Address No <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes <br /> TYPE OF WORK (CHECK): NEW WELL❑ ❑ E RO❑ ITI P❑P INSTALLATION . <br /> � PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ .OH <br /> REPLACEMENT❑ ry i <br /> -' Sewer Lines'. Pit Privy <br /> I DISTANCE TO NEAREST: Septic Tank Ces&pool/Seepage Pit-.----�-- ---'�-Other. - - <br /> Sewage Disposal-Field- - - . <br /> Public Domestic Well <br /> ✓ �. Property Line <br /> Private Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ INDUSTRIAL pia. of Well Casing <br /> ElDOMESTIC/PRIVATE ❑ DRILLED "A- (JY <br /> ' 13 DRIVEN Gauge of Casing <br /> 11DOMESTIC/PUBLIC j] GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION 11 �r <br /> 13ROTARY Type of Grout <br /> 11 CATHODIC PROTECTION Other Information U� CUh•e <br /> ❑ DISPOSAL <br /> El OTHER <br /> Surface Seal Installed By: <br /> ❑ GEOPHYSICAL <br /> PUMP INSTALLATION:• Contractor <br /> H.P. <br /> `Type of Pump <br /> PUMP REPLACEMENT:: ❑ State Work Done <br /> PUMP REPAIR: 13 State Work Done Approximate Depth <br /> DESTRUCTION OF WELL: Well Diameter r <br /> Describe Material and,Procedure <br /> I hereby certify that I have prepared this application and,that`the work will be done in accordance with San Joaquin County C <br /> ordinances, state laws, and rules and regulations of the Sa 6aquin Local Health District. V, <br /> Home owner or licensed agent's signature n suifies th6 ch manner tas to become fsubject to workmany that in the 's compensation nce of the work f laws of California."or which this <br /> is issued, I shall not employ any person <br /> s,the following:"I certify that in the performance of the work for which this <br /> Contractor's hiring or sub-contracting signature certifiee. f <br /> permit is issued, I shall employ persons subject to workman s compensation laws of California." <br /> I will cal for a Grout Inspection rior to grouting and a final inspection. pate: �+ <br /> Title' <br /> Signed X '(Draw plot Plan o L-Re erse Side) <br /> �* FOR DEPARTMENT USE ONLY <br /> PHASE I L>��r� Date <br /> Application Accepted By } <br /> Additional Comments: phase Ill Final inspection <br /> Phase li Grout Inspection Date <br /> Inspection By <br /> �.j Date Inspection By <br /> July 1 & <br /> Fee Is Due.• C3 ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH El January 1 &Received By January 31 ❑ uy ReceiveJuly 31 <br /> Rd MIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION , <br /> PLUS - <br /> PENALTY <br /> OTHER I I <br /> A 111111110 <br /> OTHER <br /> Issuance Date Mailed <br /> Received by Date Receipt No <br /> Permit No� Delivered <br /> 1601 E.HA2ELTON AVE..P.O.Boa 2009 STOCKTON,CA 95291 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />