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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> ,- - (For Non-Transferable, Revocable, Suspendable) �' <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WELL ' <br /> WATERT QUALITY <br /> (COMPLETE IN TRIPLICATE) I <br /> Application is hereby madeto theSan Joaquin Local Health Districtfora permit to construct and/or install thework herein described.This application is 0 <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 21750 E . River Rdeaimi. East- of Van A11cqrTR,0rk,4 imi. --south of River Rd <br /> Owner's Name Collier Farms-,_ Inc Phone' <br /> Address P.O. Box 158 City F. ce 1 on. C2 - <br /> Contractor's Name Hennings Bros. License# 290813 Business Phone <br /> Contractor's Address 3525 Pelandale Ave. j Mod , Emergency Phone 2 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD7 Yes X No i <br /> TYPE OF WORK (CHECK): NEW WELL It DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ t <br /> REPLACEMENT❑ <br /> y <br /> DISTANCE TO NEAREST: Septic Tank 1/8mi. Sewer Lines Pit Privy <br /> Sewage Disposal Field none 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 Exceivation 2811 ' <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 1 611 <br /> ❑ DOMESTIC/PUBLIC © DRIVEN Gauge of Casing 11ra <br /> IR IRRIGATION M GRAVEL PACK Depth of Grout Seal none <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout nOTle <br /> ❑ DISPOSAL ❑ OTHER Other Information Slab-by. Owner <br /> ❑ GEOPHYSICAL ,a 4 Surface Seal Installed By: none <br /> PUMP INSTALLATION:�� Contractor' <br /> Type of Pump H.P. Q <br /> PUMP REPLACEMENT: "r ❑ State Work Done l <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 for which this i <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br />` I will all for a Grout Insp ' n prior t grouting an final i clion. <br /> Signed X � � Date: / <br /> Draw Plot Plan on Reverse S�e)1 t <br /> FOR DEPARTMENT USE ONLY <br /> PHASEIn <br /> Application Accepted By Date �� / 2 <br /> Additional Comments: I <br /> Phase II Grout Inspection a III Final inspection <br /> Inspection 8y Date Inspection By Date -zz <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> "PRORATION <br /> i <br /> PLUS <br /> I PENALTY - <br /> I OTHER <br /> i <br /> OTHER - <br /> 71 <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 />