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Applications Will Be Processed When Submitted Properly Completed. Be SureTOsign IneAppimatiun.Y FOR OFFICE USE: ;" <br /> APPLICATION `" <br /> (For Non-Transferable, Revocable, Suspendable) PUMP&WELLIT <br /> ENVIRONMENTAL HEALTH PERMIT 5 Cpl^ l r <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) f � <br /> strict for permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health Di <br /> rules and regulations of the SaL©dauin Local Health District.made in compliance with San Joaquin County Ordinance No. 1862 and the <br /> .Exact Site Address 11.4 2 N Mickie Grove Rd Cit /Town <br /> Sam LeC uca Phone 982--5182 T <br /> Owner's Namep� t <br /> Address C1p� �— � —) City <br /> Contractor's Name They° or Well Drilling License# 391542 Business Phone —2 <br /> Contractor's Address 13;"33 BnrdenRdUar_d Emergency Phone 36)-6982 <br /> Is Certificate of Workman's Compensation insurance on File With SJLHD? Yes No N El7ip� Dtf®AS <br /> TYPE OF WORK (CHECK): NEW WELL I DEEPEN ❑ RECONDITION❑ DESTRUCTIO ❑ T <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r <br /> REPLACEMENT❑ �t <br /> DISTANCE TO NEAREST: Septic Tank 1�.1.o fes.__ Sewer Lines 140f t Pit Privy <br /> Sewage Disposal Field 145 ft. Cesspool/Seepage Pit ——-- Other- <br /> Property Line__17_ffvate Domestic Well --- Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ® CABLE TOOL Dia. of Well Excavation tr r f <br /> ft <br /> © INDUSTRIAL ff <br /> 11 DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing - 125 1,1811 <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal _�- <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout _9 Sk gr0lit <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 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 fly, <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will all for a Grout Ins ection p for to routing and a final inspection,_ <br /> Signed X Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY �,��� . <br /> PHASE <br /> Application lAccepted By - O� Date7 - ,— <br /> —= <br /> Additional Comments: <br /> h II Grout Inspection ti Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT ❑ PER SITE EI EACH ❑ January"'! &Received By January 31 ❑ July I &Receiv July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ~ Received by DatA Receipt No. Permit INo. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 El HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />