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Applications Will Be Processed When SubmittedProperlyL:omple►ev.v� C <br /> APPLICATION <br /> FOR OFFICE USE: (For Non-Transferable,Revocable,Suspendable) ! PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ! "� <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) <br /> Application is hereby made tothe San Joaquin Local Health District for a permit to construct and/or install thewark herein described.This <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San oaquin Local HeaRh District. <br /> City/Tow <br /> Exact Site Address <Z <br /> Ph . <br /> Owner's Name City <br /> Address License Business Phone <br /> i <br /> Contractor's Name Emergency Phone <br /> Contractor's Address No <br /> is Certificate of Workman's ompensation Insurance an Fil With SRECO Yes ❑ DESTRUCTIO�N,,❑ / <br /> TYPE OF WORK (CHECK): NEW WELL 13 DEEPEN ❑ OTHER ITIO UMP INSTALLATION&� QUMP REPAIII <br /> WELL CHLORINATION ❑ WELL ABANDONMENTL <br /> REPLACEMENT❑ Sewer Lines Pit Privy <br /> DISTANCE TO NEAREST: Septic Tank Cesspool/Seepage Pit Other <br /> Sewage Disposal Field Public Domestic Well <br /> Property Line Private Domestic Welk <br /> INTENDED USE TYPE OF WELL <br /> 13 CABLE TOOL Dia. of Well Excavation <br /> ❑ IN RIAL Dia. of Well Casing <br /> DOMESTIC/PRIVATE ❑ DRILLED <br /> ❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION ❑ ROTARY Type of Grout <br /> 13CATHODIC PROTECTION ❑ OTHER Other Information <br /> ❑ DISPOSAL Surface S ,i Installed By: <br /> 11GEOPHYSICAL . <br /> PUMP INSTALLATION: Contractor H P � <br /> r <br /> Type of Pump <br /> PUMP REPLACEMENT: ❑ State Work Done -�- <br /> PUMP REPAIR: ❑ State Work Done Approximate Depth <br /> DESTRUCTION OF WELL. Well Diameter <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. C_ <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the pertormance of the work for which this permit <br /> 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 for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will Cr a Grout I sp ti grouting and a final inspection. Y <br /> if <br /> Date: <br /> � Title: <br /> Signed __ -oma (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> TPHASEI Date <br /> tion Accepted ByAdtonal Comments: hag al Inspection <br /> Phase II Grout inspection Date <br /> inspection By <br /> Date Inspection By <br /> ❑ January 1'&Received By January 31 ❑ July 1 &Received'By July 31 <br /> Fee Is Due: ❑ ANNUALLY [2 PER UNIT <br /> [3 PER SITE EACH REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> � L4S <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER -q <br /> Permit Nv-. <br /> ssuance ale Mailed <br /> Date Receipt No. P.O.Bo: ' Delivered <br /> Received by 1601 E.HAZELTON AVE., 2009�, gTOCKTON,CA 95201 <br /> APPLiCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />