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Applications Will Be Processed When Submitted Properly Completed. Be Sun Sgn The Application. <br /> FOR OFFICE USE: APPLICATION L ' <br /> (For Non-Transferable, Revocable, Suspendable) D E G 29 19 .81 <br /> ENVIRONMENTAL HEALTH PERMIT lr4PLotV <br /> UMP ELI <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY HEALTH DISTRICT <br /> 4_ Application is.hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is <br /> made in compliance with Sari Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address k. 10030 E. Liberty Rd City/Town Galt <br /> s <br /> Owner's Name Phone <br /> Address City G <br /> Contractor's Name Thayer Well Drilling License#_391542 Business Phone----748-2456 <br /> Contractor's Address 1-3.2 3 3 B _ '� �`: <br /> orden Rd =Emergency Phone 8-2 -6 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? -Y-esNo X No Employees <br /> TYPE OF WORK (CHECK): NEW WELL El- DEEPEN El RECONDITION❑ _ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ ,WELL-ABANDONMENT ❑ -OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR 11 � <br /> REPLACEMENT <br /> DISTANCE TO NEAREST: Septic Tank 4001+ Sewer Lines_t 001 Pit Privy none <br /> Sewage Disprosal Fiefd 4001+ -:��-Cesspool/Seepage Pit .1I One .1 :5L14 P ,� 0ft <br /> Property Line 3201 Private Domestic Well. 40!XI-f-Public Domestic Well notlei <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 49 CABLE TOOL Dia, of Well Excavation-16" to 2001 then 14 � t <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing tb <br /> r <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing 3- '1611 <br /> IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ` <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: (� <br /> PUMP INSTALLATION: Contractor 9 t elQ <br /> Type of Pump 1H, <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done " <br /> DESTRUCTION OF WELL: ,F Well Diameter Approximate Depth , <br /> Describe aN t-eriatrand.Procedtire _ 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San7this <br /> y <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. 1 <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work fort <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 9941 r a Grout Inspection grouting and a final inspection. <br /> Signed X f '. •""F"-Title:!n Date: tw <br /> I't�r Well rifling (Draw Plot Plan on Reverse Side) 4 <br /> FOR DEPARTMENT USE ONLY <br /> PHASEI <br /> Application Accepted By I Date O <br /> Additional Comments: <br /> se 1 Grout Inspection Ph se 1 1 inal Inspection <br /> Inspection By Date Inspection By to <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING, REMITTANCE $ REMIT <br /> :BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE �� �' Y 6 f <br /> _ f <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> .f jj q <br /> Received by- Date Receipt No. Permit No, Issu nce Dae Mailed Delivered - - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES _x 1601 E.HAZELTON AVE.,P.-O.Box 2009 STOCKTON,CA 95201 <br />