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Applications Will Be Processed When Submitted;Properly Completed. Be SureToSignTheApplication. <br /> I FOR OFFICE USE: n APPLICATION DO <br /> " c � � <br /> P (For Non-Transferable, Revocable,Suspendable) <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> l' (COMPLETE IN TRIPLICATE)r'S WATER QUALITY <br /> O(� (sc, --WATER <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 Ordinan a No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 0 E j�'`"'�'a'City/Town <br />` CITY f MANT C Phone - <br /> fr Owner's Name <br /> Address Dept. Of Public .Works City <br />: Contractor's Name Henning Bros . License C5��MI3usiness Phone 5 2 F-1.5 7 _ k <br /> Contractor's Address 3525 Pelandale Emergency Phone 545-1189 _ <br /> I Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK: NEW WELD DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR El <br /> CREPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank ----- Sewer Lines .—a2— Pit Privy --- <br /> t. Sewage Disposal Field ---- Cesspool/Seepage Pit — Other <br /># Property Line 2 5 Private Domestic Well Public Domestic Well <br /> k <br /> r INTENDED USE TYPE OF WELL <br /> F ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 2.4 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN , Gauge of.Casing <br /> > ❑ IRRIGATION fkGRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION fk1ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information- <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> L- <br /> PUMP INSTALLATION: Contractor Cent T, <br /> Type of Pump Deep well 1 urhi n H.P. 100 <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 l7 <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 permitC <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 w call for a Grout In prior to grouting and a final 'nspection. <br /> Signed X Title: F Date: <br /> (Draw Plot Plan on Reverse Side) Ir <br /> I FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE I <br /> r Application Accepted By <br /> Date <br /> Additional Comments: <br /> Phase II Grout Inspection Phase III Final Inspection <br /> Inspection By Date Inspection By Date E <br /> f <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 $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> r FEE F-2— L` <br /> LESS <br /> PRORATION III IlL 117 <br /> Zn� <br /> _ <br /> PLUS � f L <br /> PENALTY 0 <br /> OTHER ` ` <br /> ` Ii 1 c d� w joy) aY!�h Jdu6'A r f6 Coy-�wf <br /> OTHER <br /> Sid <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 95287 <br /> _ v _ ,dam <br />