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Applicati oPio essed When S66mitted Properly Completed.Be Sure To Sign The Application. <br /> FOQ^« E USE: APPLICATION <br /> cy e� <br /> e ({ 'r Non-Tra erable, Revocable, Suspendable) PUMP &WELL <br /> �N.V4R�'iCJ,WNTAL HEALTH PERMIT <br /> �C�''�� J QUALITY <br /> (COMPLETE IN TRIPLICATE) ��� , 1 1 WATER Q <br /> Application is hereby madetotheSanJoagAFJ-l�N'�al Health Districtfora permitto constructand/or install thework herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address -�00"SO 0-f-O- lxt/<C,- kA. -300' Y✓e51-O;Aeche'ttg eLity/Town ®Llilden <br /> Owner's Name ©/r'!1 /Cerra i^[ Phone �0 ��3 cP 03 <br /> Address 596 ArC lh a j-d4le Ad. City L Inden <br /> Contractor's Name dance Drillers Drilling Corp. License#327123 Business Phone <br /> Contractor's Address L I nctc_-� 9f�a3l(__ Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes_�___ No <br /> TYPE OF WORK (CHECK): NEW WELL 1A DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ r� <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines,2 <br /> 0a '� 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 '19 CABLE TOOL Dia. of Well Excavation <br /> �I DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal 52 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout S6k m <br /> ❑ DISPOSAL ❑ OTHER Other Information N©b P <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 /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <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 will call for G ut nspection prior to grouting and a final inspection. �/I <br /> Signed X Title: ! SSI �- Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I �,� CI-Al- <br /> Additional <br /> p1 <br /> Application Accepted By ` ` �'r�" Date O� <br /> Additional Comments: <br /> h Grout.inspection // j Phase III Final Inspection <br /> Inspection By /�nI ' Date 1H 3 �!� Inspection By Date <br /> Fee IS Due: ❑ ANNITALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> 1 It L � �` <br /> FEE CIV, <br /> \ <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. I suance date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 96201 <br />