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Ap li_c. jlonsWill Be Processed Wh��bmitted Properly Completed. Be Sure To Sign The Application, M <br /> FOR OFFICE USE: v UL 11987 APPLICATION <br /> (For Non-Transferable, Revocable,Suspendabfe) PUMP&WELL <br /> SA[,J LTIA Ur�`�._�^ NMENTAL HEALTH PERMIT <br /> HEA�Tf-� DIST �L! <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 Joaq 'n County Ordinance No. 1862 and th rules and regulations of the San, Loc I Healt District, <br /> Exact Site Address <br /> City/Town d J' <br /> Owner's Name LLE <br /> AddressJi <br /> 's Phone <br /> I �� City ' <br /> Contractor's Name U License# <br /> Qd ��a�� Business Phone <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes__ <br /> I TYPE OF No <br /> WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ ' DESTRUCTION❑ - - } <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ -PUMP REPAIR❑ <br /> REPLACEMENT 69 <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines ' <br /> Pit Privy <br /> Sewage Disposal Field Cesspooi/Seepage Pit <br /> Other <br /> INTENDED USE Property Line Private Domestic WePublic Domestic Well � I. <br /> TYPE OF WELL <br /> 13 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 1A DOMESTIC/PRIVATE -4 ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> 11 IRRIGATION. Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> C1DISPOSAL Type of Grout <br /> El OTHER Other Information <br /> GEOPHYSICAL r Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump P <br /> PUMP REPLACEMENT: 19 State Work Done u <br /> PUMP REPAIR: ❑Estate Work Done O <br /> DESTRUCTION OF WELL: Well Diameter <br /> • � Describe Material and Procedure Approximate Depth <br /> � K , <br /> I hereby certify that I Have prepared this application and that the work will be done in accordance with San Joaquin County r� <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. v 1 <br /> Home owner or licensed agent's signature certifies the following."I certify that in the performance of the work forwhich 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_contracling signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued;I-shall employ persons su to workman's compensation laws of California." <br /> I w' all for Grout Insp ction pri o III and a final inspec ' n. <br /> Signed X Title: 7 x <br /> Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASEI FOR DE ARTMENT USE ONLY <br /> Application Accepted y D. <br /> Additional Commen s: Date 2:� <br /> h se I Grout Inspection ' h e III Final Inspection <br /> Inspection By Date <br /> Inspection By CS1 Date <br /> Fee Is Due: ❑ ANNVALLY � ` <br /> ❑ PER UNIT ❑ PE�R SITE ❑ EACH ❑ January 1 &Received'B Januar 31 <br /> Y Y ❑ July 1 &Aeceived By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> $ DATE DATE' REMITTED AMOUNT DUE CHECKED <br /> FEE <br /> ' AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS _ <br /> PENALTY <br /> OTHER { <br /> OTHER - - <br /> �� S {� <br /> Received by Date Receipt No. Permit No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - Issuance Date Mailed Delivered <br /> 1fi01 E.HAZELTON AVE.,P.O,Box 2009 STOCKTON,CA 95201 e di- <br />