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Applications Will Be Processed When Submitted Properly Comple euTt igTNe Alic . <br /> ]FOR:OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Sus ble)NOV 2l 1*0 PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY ' "t'`Itf <br /> (COMPLETE IN TRIP KATE) �A�t s g" <br /> Application is N TRI made to the San Joaquin Local Health Di strict for a permit to construct and/o Instj1A1 kQ!fn described.This application is <br /> ns of the San Joaquin Local Health District. <br /> made in compliance with San Joaquin Coun y Ordinance No. 1862 and the rules and regulatio <br /> ' .2S©� City/Town �tDC�c 7`os� <br /> Exact Site Address 1ST© Gtr6a� lF' � � _ <br /> Phone �� S 0 <br /> Owner's Name U�i'► Brans/a d 5—roc k-tQ�__ f <br /> Address o F &&S" ML' City <br /> Contractor's Name urvlance VrIllerS Wrilling Urp. License#311923 Business Phone f31— 4'16 JV D <br /> Contractor's Address Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITIONX DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑" PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <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 12 <br /> /s <br /> ❑ INDUSTRIAL �$ CABLE TOOL Dia. of Well Excavation <br /> lD" <br /> ❑ DOMESTIC/PRIVATE 13 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 /> ❑ 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 Approximate Depth <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. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance 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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call to rou nspection prior to grouting and a final inspection. <br /> Signed X Title: Fre.s i d e in Date: <br /> .20--90 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY `�_9—,! <br /> � <br /> PHASE I Date��— <br /> � <br /> Application Accepted By <br /> Additional Comments: <br /> Phase II Grout Inspection Phase 111 final Inspection <br /> Date Inspection By Date /14 <br /> Inspection By ,/�`j <br /> Fee Is Due: 13 ANNUALLY C1 PER UNIT El PER SITE 11 EACH 11 January 1 &Received'6y January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 10 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />