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Applications Will Be Processed When Submitted ProperlyCompletea. tie bure Ioaiign rrrV..YNr.a.... ,• <br /> APPLICATION <br /> FOR OFFICE USE: <br /> (For Non-Transferable, Revocable,S pendable) PUMP&WELL <br /> ENVIRONMENT HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) <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 Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Siteddress 3/8 Mile South of Highway 0-�.. <br /> City/Town Escalon <br /> �'Z_907 VonU Latin Phone <br /> Owner's Name Ken <br /> City <br /> Address — � <br /> Contractor's Name License#360-851 Business Phone 8G7 0394 <br /> Contractor's Address 25 Reed Road Emergency Phone 847-0 94 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes___y— No <br /> TYPE OF WORK (CHECK): NEW WELL® DEEPEN ❑ RECONDITION C3 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION IN PUMP REPAIR❑ <br /> Oq <br /> REPLACEMENT❑ A20 <br /> DISTANCE'TO NEAREST: Septic Tank �117ti)� Sewer Lines ���� - Pit Privy _ -172-6- - <br /> Sewage Disposal Field Cesspool/Seepage Pit _ �/L11 Other _ <br /> i <br /> Property Line�Private Domestic Well ��Public Domestic Well�..� ��e` <br /> INTENDED USE TYPE OF WELL <br /> 11tf <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> 11 DRILLED Dia. of Well Casing 11 <br /> ® DOMES�1'IC/PRIVATE , <br /> 11 DOMESTIC/PUBLIC 11DRIVEN Gauge of Casing11 _ <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Rn 1 <br /> ❑ CATHODIC PROTECTION K1 ROTARY Type of Grout Bentonite <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor Martin P <br /> Type of Pump H.P. <br /> 14 <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 thework 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 <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I ll for a Grout Inspect! p for to grouting and final inspecti <br /> Signed X Title: Dale: <br /> *W/97S <br /> (Draw of Pian on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHAS <br /> Application <br /> 1 <br /> Application Accepted By Date <br /> Additional Comments: + <br /> 5al�-Il Grout Inspection P ,se III Final Inspection <br /> Inspection By Date�Z¢` Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceivedREMITuly 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE O <br /> V <br /> LESS <br /> PRORATION <br /> PLLS <br /> 35 <br /> PENALTY <br /> OTHER <br /> OTHER <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 />