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Applications Will Be-Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> -EOR OFFIr.E USES APPLICATION <br /> _. "'- (For Non-Transferable, Revobable, Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is herebymadetotheSanJoaquin Local Health Districtforapermittoconstruct and/or install thework herein described.This applicatiorfis'� <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 Southiind Ave _ City/Town <br /> Owners Name ary.Ballard Phone <br /> 649 <br /> a„ <br /> Address _. F8??`Snuthland._9ss. _ City — <br /> Contractor's Nameantieca <br /> of rse#-'290813 Business.Phone <br /> Contractor's Address _ 52 1�p1:4 ]dale AVP �M dactp 4 Emergency Phone. s ,, <br /> 545�1 IA <br /> � - <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE'OF WORK (CHECK); ^'NEW WELL IR-"- DEEPEN O RECONDITION ET.v. DESTRUCTION❑ —W- - <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ <br /> REPLACEMENT❑ PUMP REPAIR <br /> DISTANCE TO NEAREST: Septic Tank - 1 no lSewer Lines Pit Privy <br /> Sewage Disposal Field 1601 Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ' 11 CABLE TOOL Dia, of Well Excavation }1 <br /> Q DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casingrr <br /> ❑ DOMESTIC/PUBLIC ❑ Rim <br /> DRIVEN Gauge of Casing _. 16Q wall <br /> ❑ IRRIGATION ® GRAVEL PACK _ Depth of Grout Seal _ 501 <br /> ❑ CATHODIC PROTECTION IkROTARY Type of Grout Bentonite <br /> ❑ DISPOSAL <br /> ❑ OTHER Other information <br /> ❑ GEOPHYSICAL ` <br /> r 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 bone , <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> ' - 1 <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 <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 tail for a Grout Inspection prior to grouting and a final inspection. �,� <br /> Signed X Hennings Bros. Drilling Co. Inc. Title: b . lL Date: 11-16-83(Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI t <br /> Application Accepted By Date lZ�r f <br /> Additional Comments: <br /> Phaa II Grout Inspection P ase III Final Inspection . <br /> Inspection By Date 12- `J3 h Inspection By /iIDate <br /> Fee Is Due: 13 ANNUALLY • ❑ PER UNIT ❑ PER SITE EACH ❑ January 1 8 Received B Januar 31 r� <br /> Y Y IJ July 1 8 Received By July 31 <br /> If <br /> BASE EXPLANATION iBILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE AMOUNT <br /> Or 00 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER y <br /> Received b � <br /> Y ate 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 95201 <br />