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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) PUMP&WELL <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is 0� <br /> ' made in compliance with San Joaquin County Ordinanc No.1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 21750 E River Rd -dLMi East- of Van A1104/TUns9 lm� south of River Rri_ <br /> Owner's Name Collier Farms Inc a Phone <br /> ' Address _ P.O. Box 158 City <br /> Contractor's Name Hennings BrOS License# 29081 3 Business Phone 5 5-1185 <br /> Contractor's Address.525 Pelandale Ave. ii MOde Emergency Phone 545-02'71� <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X— No <br /> ' TYPE OF WORK(CHECK): NEW WELL DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT[] <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 Excavation 28"1 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia.of Well Casing 16" <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing "Ga <br /> IRRIGATION KI GRAVEL PACK Depth of Grout Seal none <br /> ' ❑ CATHODIC PROTECTION EXROTARY " Type of Grout none <br /> ❑ DISPOSAL ❑ OTHER Other Information Slab-by. owner R <br /> ❑ GEOPHYSICALSurface Seal Installed By: none � <br /> 0� <br /> PUMP INSTALLATION: '' onlrator <br /> cCA <br /> It�yal�9 Type of Pump H.P. .Q <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> .i <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter ., Approximate Depth <br /> Describe Material and Procedure It <br /> t - I hereby certify that 1 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, 1 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 /> 1 will all for a Grout Ins n prior tgrouting an linal i tion. <br /> Signed X Date. 37 / <br /> raw Plot Plan on Reverse e) <br /> FOR DEPARTMENT USE ONLY J <br /> PHASE 1 ((1 2 <br /> Application Accepted By Date <br /> Additional Comments: <br /> ' Phase 11 Grout Inspectiona If lost Inspection <br /> Inspection By Date Inspection ByV 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 /> ' BASE EXPLANATION BILLING REMITTANCE B AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ' LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ' OTHER �Q <br /> OTHER ?/ <br /> Received by Date Receipt No. Permit NO. -=�—Issuance Date, Mailed - Deli"M <br /> APPLICANT—RETURN ALL COPIES TO:- ENVIRONMEWAL MMLTN PERMMS!RVICES IBM E.r1AZELTON AVE.,P.O.Bot 20M STOCKTON,CA 9301 <br />