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ApplicationsWill BeProcessed When SubmittedProperly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for a 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 Site Address 16866 Steingull Rd City/Town ESCalon <br /> Owner's Name T,oll Yalland Phone 462-7197 <br /> Address 2 Q w___4th _ City Escalon <br /> Contractor's Name Clark Well & Equipment License 4-571-560 Business Phone 2462- 597 <br /> Contractor's Address 2--Q24 E, ChSTtPr . y Emergency Phone NA <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL-0 DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR C1 �l <br /> REPLACEMENT❑ / <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Fie}d Cesspool/Seepage Pit Other w <br /> Property Line 414 Private Domestic Well Public Domestic Well 67 <br /> INTENDED USE TYPE OF WELL <br /> 0 INDUSTRIAL ❑ CABLE TOOL Dia, of Well Excavation ZR" <br /> DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing 6 ,/8" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing CL 160 Pyr <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 50 <br /> ❑ CATHODIC PROTECTION [:R ROTARY Type of Grout Bentonite <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 1 <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 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 d, I shall employ persons subject to workman's compensation laws of California." <br /> I wits out ct' prior to grouting nd a final inspection. <br /> Signed X Title: Cwner Date: 26 JU13/ 1982 <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I '' z <br /> Application Accepted By rt�.. Dated <br /> Additional Comments: <br /> h se II Grout Inspection Com-, Phase III Final Inspection <br /> Inspection By Date . : — Inspection By LHLr) a Date <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 DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 3e c, <br /> LESS <br /> PRORATION <br /> PLUS <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 PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />