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w I Btt n"Itrad-PrO0066TedWhe mittedProperly Completed. Be Sure To Sign The Application. <br /> F�tR OFFICE USE: LaA <br /> PPLICATION -r h� ..,gyp <br /> IY <br /> r AR 23 'N1mon-Transferable, Revocable, Suspendable} ��n �"�tv� <br /> ' <br /> ENVIF ONMENTAL HEALTH PERMIT PUMP&WELL f <br /> L 6 <br /> iSAN 1".,_, <br /> (COMPLETE IN TRIPLICATE) 1 TTln �� itilt WATER QUALITY <br /> I Application is hereby made to theSWo�faLoca ealthDlstrictforapermittoconstructand/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 186 and the rules and regu-Mations of the San Joaquin Local Health District. <br /> Exact Site Address `• 5� .t/P h-t� . <br /> T_n(�ty/Town L <br /> Owner's Name Dail Phone 31--.$ 406 1.0 S'—d 3D—D/ <br /> _ city -5Tkv� . _ r <br /> Address urvtanceDrillers DrillingCorp, <br /> Contractor's Name CorLicense#�a 779 .3 Business Phone _ <br /> Contractor's Address ��cr2. ___ r,C — L-ih�{er�.__ Emergency Phone <br /> i is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes I/ No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONR PUMP REPAIR 11 <br /> REPLACEMENT❑ <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 USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation ti <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge Of Casing <br /> I IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ; <br /> ❑ CATHODIC PROTECTION ❑ ROTARY T <br /> ype of Grout � T <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> I' ❑ GEOPHYSICAL urf e Seal Installed By: � w <br /> PUMP INSTALLATION: Contractor Pllrviance Drifters Driingorp. <br /> , F <br /> t Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> F PUMP REPAIR: ❑ State Work Done r <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:-1certify that in the performance of the work for which this permit e <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 C ` <br /> permit is issued, I s employ persons subject to workman'socompensation laws of California." RR <br /> c ��v <br /> �Lwill call for out spection_prior to grouting:and.a,.final insp`eclion. <br /> r ' <br /> Signed X _-Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By f <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By. Date Inspection ByW- Date 36 Lkl <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE '❑ EACH ❑ J 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> I BILLING REMIT ANCE $ <br /> l BASE EXPLANATkON DATE DATE REMITTED AMOUNT DUE CHECKED <br /> 4 <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> 1 PLUS <br /> k PENALTY <br /> i <br /> OTHER <br /> i <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.D.Box 2009 STOCKTON,CA 95201 <br />