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Applications Will Be Processed When Submitted Properly Completed. B r�'' o Sign TbteAdrpplicati j�`, <br /> FOR OFFICE USE: APPLICATION <`Q� y i� %CJ <br /> (For Non-Transierable, Revocable, Suspends 1Y!`` .�� <br /> kENVIRONMENTAL HEALTH PERMIT 4MP&WELL <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY \N <br /> Application <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 w.ith-San Joagain-County-Ordinance-No:r1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address '1-11875 CoppPrOpOl s,Rd:; City/Town Stacktnn <br /> ` •�' <br /> 462-0581 <br /> Owner's Name Jess ThorStadt Phone <br /> Address same City <br /> — . <br /> 931-3210 <br /> Contractor's Name _Moor's' an�`5 7atE?r—, �YSt FFIS License# 26���6 Business Phone - <br /> Contractor's Address 424 3 Cherryland Ave. <br /> _ Emergency Phone same as above- <br /> pal <br /> Is Certificate of Workman's Compensation Insurance On File With SJLHD? Yes No O <br /> TYPE OF WORK (CHECk): NEW WELL El DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ . <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ P-UMPTINS'f ACCATIUWq PUMP REPAIR <br /> REPLACEMENT❑ � �] <br /> f 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 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor. <br /> T e of_Pump ,-t- sLlbff ersible . .__ �.. H.P. - <br /> .�ysp - - pu- - e o _pump an ins a e new pump <br /> PUMP REPLACEMENT: u State Work Done 4 <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I 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. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work forwhich this permit <br /> j is issued, I shall not employ any person in such.manner as to become subject to workman's compensation laws of California." <br /> I 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 call for a Grout Inspection prior to grouting and a final inspection, <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEP RTMENT SE ONLY <br /> PHASEI <br /> WO 13 <br /> Application Accepted By Date <br /> Additional Comments: - S-w <br /> Phase It Gr ut Inspection Phps I na I spection lN�a <br /> Inspection ByDate Inspectiono <br /> A <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH _ ❑ January &Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> POUNT <br /> NT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I Received by Date ;-A Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT'—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />