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-� --- =.- <br />( Applications Will Be Processed When Submitted Properly Completed. Be sure <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 District for It 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 JoaiPOLocaItOnHealth District. <br /> Exact Site Address 14 GilliS Rd City/Town 6LLorK1on <br /> Owner's Name Camera Brothers Farms Phone 727 <br /> o- on <br /> 145 illis Rd city <br /> Address 2-5597Contractor's Name Clark Well-& Equipment License# 3715 0 Business N <br /> Contractor's Address 202 one_ <br /> -E. Charter WaV Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No 61 <br /> TYPE OF WORK (CHECK): NEW WELLXX DEEPEN El RECONDITION 13 DESTRUCTION❑ d <br /> WELL CHLORINATION 11 WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ �} <br /> REPLACEMENT❑ Ag Well in Orchard <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USETYPE OF WELL <br /> + 13INDUSTRIAL # EPICABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN w' Gauge of Casing 0 <br /> XXIRRIGATION ❑ GRAVEL PACK Depth of Grout Seal N <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <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 <br /> i <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 Iaws,'and rules and regulations of the San Joaquin Local Health District. <br /> Ho owner r licensed agent's signature cerlities the following:"I certify that in the performance of the work for which this permit <br /> is sued, I s II not employ any rson in such manner as to become subject to workman's compensation laws-of California." <br /> ontractor' hiring or sub-co actin signature certifies the following:"I certify that in the performance of the work for which this <br /> permit ' ssued, I shall em oy p ns subject to workman's compensation laws of California." . <br /> Ill call for a Grout In do p or to grouting and a final inspection. <br /> Signed X `- ; Title: <br /> Date:Sept.18 ,198 <br /> i (Draw t Plan on Reverse Side) <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> PHASE IO <br /> Application Accepted By Date <br /> Additional Comments: <br /> Phase It Grout Inspection Phas I Final inspection <br /> Inspection By Date Inspection By Date — � <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Re ed By January 31 ❑ July 1 &Received By July 31 <br /> r. - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> F PENALTY - <br /> OTHER <br /> OTHER u <br /> Received by Date Receipt No, Permit No. Is uance ate Mailed Delivered <br /> i <br /> - APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9526 <br />