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Applications Will Be Processed When Submitted Properly Completed. Be-Sure To Sign The Application. <br /> .FOR oFr=lca_use: - --APPLICATION ra j".0 <br /> _ (For <br /> < Non-Transferable, Revocable, Suspendable) WELL <br /> PUMP <br /> f �1 <br /> •t ENVIRONMENTAL HEALTH_ PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County,Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address r�Rr ill' �/Q �,� ` 'r. ' Q A Qtq+ e_ CA.- City/Town N C AJ <br /> Owner's Name c fi ` i�� .t- C <br /> �. Phone [ <br /> Address e r City <br /> Contractor's Name J C o¢ ci l�.G.s"1 License#'a7W#D Business Phone 6 <br /> Contractor's Address C , Emergency'Phone- <br /> i' Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ - DEEPEN ❑ RECONDITION.❑. DESTRUCTIONK <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ 1 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 12 <br /> IN IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: ^-�`� Well Diameter r <br /> Approximate Depth <br /> Describe Material and Procedure L W <br /> i L e 4 F' <br /> hereby certify that I have prepared this application Xat 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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit f <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.;.r <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this a <br /> permit is issued, i shall employ persons subject to workman's compensation laws of California," <br /> I will call for a Grout Inspection prior to grouting and a final inspection. <br /> Signed X Title: <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY r <br /> PHASE I <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase If Grout Inspection Ph a Ill F'nal Inspection <br /> Inspection By. Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1a Received By July 31 <br /> " BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION <br /> . ©ATE OATS REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS t? <br /> PRORATION <br /> PLUS <br /> PENALTY - - - - <br /> OTHER <br /> OTHER J-- <br /> AZ;E [f <br /> Received by Dat - Receipt No. Permit No - ssu nc Daie Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> s <br />