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! "Applications Will Be Processed When Submitted Properly Completed. Be S �ogl I�refAllic�ati UU <br /> FOR OFFICE USE: APPLICATION <br /> I (For Nan-Transferable, Revocable, Su AL <br /> &WELL <br /> ENVIRONMENTAL HEALTH PERMIT P <br /> SAN JOA €CCAL V <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY u�p T DISTRICT <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the46r! Ir le ,indescribed.This application is <br /> i, made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the Sa o I Health District. <br /> Exact Site Address 2261 P1nasco- Lane City/Town e , <br /> Owner's Name Sandy L.'. Grimes <br /> Phone 921-- 50-- <br /> Calif <br /> _ r <br /> 2261 lnasc0 lane -Lori; Calif <br /> Address _ City <br /> Machado, -nc . <br /> Contractor's Name License# Business Phone 2��- 2 <br /> —� <br /> Contractor's Address 247 N.1�4-Jack Tone Emergency Phone <br /> 002 <br /> ,t <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No pry <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATIQN ❑ WELL ABANDONMENT ElOTHER 13PUMP INSTALLATION 11PUMP REPAIR❑. �- <br /> ,} <br /> REPLACEMENT rump <br /> DISTANCE TO NEAREST: Septic Tank _50 Sewer Lines Pit Privy <br /> 4 Sewage Disposal Field Cesspool/Seepage Pit Other <br /> i <br /> E Property Line Private Domestic Well Public Domestic Well <br /> t INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> x❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing Y <br /> ❑ DOMESTIC/PUBLIC r ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION .❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information w <br /> ❑ GEOPHYSICAL h yam` Surface Seal Installed By: 1 <br /> PUMP INSTALLATION: Contractor Mac a do, Inca N <br /> t I' IS Ub <br /> l Type of Pump replaced —PumpH.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 /> E <br /> N I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 4 <br /> I ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> f <br /> Home owner 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 c for a Grout Insp ct, n prior to grouting and a final inspection. f <br /> Signed X Title: r Date: 41,w <br /> (✓L <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By Date Y-0a Additional Comments: <br /> Phase II Grout Inspection Ph a III Final Ins ection J <br /> Inspection By Date Inspection Bye ate <br /> y _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN[T ❑ PER SITE ❑ EACH ❑ January l°�B Received By January 31 ❑ July 1 &Received By Judy 31 <br /> a REMIT <br /> BASE. EXPLANATION BILLING REMITTANCE - AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> Y .r <br /> FEE <br /> LESS <br /> PRORATION - <br /> E PLUS <br /> 1 PENALTY <br /> `I�fff OTHER <br /> i� OTHEFI <br /> II Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered Y <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,A.O.Box 2009 STOCKTON,CA 95201 <br />