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rNfwt s rn afro seprf)en Submitted Properly Completed. Be Sure To Sign The'Application. _ <br /> FOR OFFICE U$ ; J , 1�a JI J� APPLICATION <br /> 71982 ( on-Transferable, Revocable,Suspendable) �p�.,/� 13 <br /> j <br /> DEC <br /> PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLI � i jA.QUiN LOCAL WATER QUALITY <br /> Application is hereby made14&kbTrHo0J&-MGFTlealth District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinan No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address �/li. fid .� y —AlIty/,Town <br /> Owner's Name '3-�/1 -�c 44, <br /> Phone <br /> Address City <br /> Contractor's Name iance Drillers Drilling Corp. License#� _ �e <br /> Contractor's Address— Business Phone <br /> Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes <br /> No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑kf DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENTZ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines <br /> 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 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN <br /> El Gauge of Casing <br /> ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY <br /> 11DISPOSAL Type of Grout <br /> OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor PurviarKe Drillers Drilling Corp. <br /> Type of Pump 24H P <br /> PUMP REPLACEMENT: J/ ❑ State WorkDone <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter w <br /> Approximate Depth p <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 forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> l wi allfor a ro pectionlprior to grouting and a final inspection. <br /> Signed-X ��S-I —� <br /> i� t Date: <br /> (Draw Plot Plan on Reverse Side) <br /> PHASE R DEPARTMENT USE ONLY <br /> Application Accepted By <br /> Additional Comments: Date l roc_ <br /> Phase II Grout Inspection ha a ill final Inspection <br /> Inspection By Date Inspection By Date c f3 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Januar - <br /> Y 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> FEE L�., <br /> LLIS_ 4 AMOUNT <br /> ESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No, Permit No. <br /> Issua ce ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P_O.Box 2009 STOCKTON,CA 95201 <br />