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Applications W111 Be Processed When Submitted rope } <br /> APPLICATION <br /> FOR UFFICT�IUSE: pUMP&WELL <br /> �� (For Non-Transferable, Revocable,Suspendable) } <br /> f ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY application is <br /> (COMPLETE IN TRIPLICATE) ork uin construct thew <br /> ( <br /> Application is hereby madetotheSanJoaq County( <br /> adpermfttos and regulatioons oftthe San JoagyLherein OG5 I)ealdthTDisthis t. <br /> { made in compliance wl Joa y _ City/Town , <br /> Exact Site Address <br /> } Phone <br /> Owner's Name City <br /> 1 Address <br /> License# Business Phone <br /> Contractor's Name : Emergency Phone <br /> Contractor's AddressNo <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? es <br /> TYPE OF WORK (CHECK): TION <br /> NEW WELL DEEPEN 11 OTHE <br /> R ITI pU❑MP INSTALLATIONC [3 - PUMP REPAIR❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT <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 Well L <br /> INTENDED USE TYPE OF WELL i <br /> 1. <br /> Cl CABLE TOOL Dia. of Well Excavation t4 <br /> ff ❑ INDUSTRIAL ❑ DRILLED Dia. of Well Casing <br /> F ❑ DOMESTIC/PRIVATE r ❑ DRIVEN Gauge of Casing <br /> t[ ❑ DOMESTIC/PUBLIC } C3 GRAVEL PACK Depth of Grout Seal <br /> 11 IRRIGATION ! Type of Grout <br /> ❑ CATHODIC PROTECTION 13 ROTARY e <br /> ❑ OTHER Other Information S <br /> ❑ DISPOSAL Surface Seal Installed By: j <br /> 1 Cl GEOPHYSICAL [' <br /> PUMP INSTALLATION: Contractor H.P. <br /> E <br /> Type of Pump <br /> PUMP REPLACEMENT: 1 ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done Approximate Depth <br /> t <br /> t DESTRUCTION OF WELL: Well Diameter <br /> � <br /> k Describe Material and Procedure <br /> i <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. <br /> Home owner or licensed agent's signatut in the pertormanceof theworkfor which this permit <br /> re certifies the following:"I certify tha <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 f the performance of the for whi th <br /> Cn laws of <br /> permit is issued, I shall employ persons subject to workman's compensatioCalifornia." _ n <br /> I wil or,a Grout In p ction for to grouting and a final inspection. j^+' _,�• <br /> Date: <br /> Title: <br /> Signed X ra Dr w P everse Side) $ 9A,;_0$ <br /> r W I <br /> FOR DEPAR MENT USE ONLY <br /> PHASE 1 Date <br /> Application Accepted Byliie r 5 e1/—P4:71:!1,1Additional Comments:�E/tJ phase 111 Final Inspection <br /> Phase 11 Grout inspection Date <br /> Inspection By <br /> Date Inspection By <br /> PER UNIT ❑ PER SITE ❑ EACH [3January 1 &Received By January 31 C1Suly 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY ❑ REMIT <br /> } BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE ( EXPLANATION DATE DATE fREMITTED AMOUNT <br /> FEE <br /> LESS <br /> I PRORATION <br /> PLUS v <br /> PENALTY <br /> OTHER <br /> OTHER t <br /> Received by ate Receipt No. <br /> Permit No. issuance Date Mailed Delivered <br /> k 1601 E.HAZELTON AVE.,P.O.Bax 2049 $TOCKTON,CA 55201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICIES <br />