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ApWaki6s Wlfi 1pe Processed Whe�a-'"mitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: F�b 5 1980 APPLICATION <br /> f (For Non-Transferable, Revocable, Suspendable) ' <br /> SAN .�i)r:0!_V1,,t �,l� PUMP&WELL 4 <br /> HEALTi DSS i'rii '1'6NMENTAL HEALTH PERMIT 6. <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> 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 San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 25992 N. ELLIOTT ROAD City/Town GALT, CA <br /> Owner's Name JOHN TOLEDO DAIRY Phone C/o VERNE VIERRA 369-9226 <br /> Address ' 25992 N. ELLIOTT RD City GALT, CA <br /> Contractor's Name SAN JOA U I N PUMP CO. License it 381012 Business Phone 369-8471 <br /> Contractor's Address 860 E. PINE ST, LOBI_, CA Emergency Phone 369--8471 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes XX No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATIONIX PUMP REPAIR <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines 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 Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION Cl ROTARY Type of Grout u <br /> ❑"DISPOSAL ES-OTHER ' —Other Information" <br /> ,t <br /> 11_GEOPHYSICAL.,,^,�Y, _ Surface Seal Installed By:.- <br /> PUMP INSTALLATION: Contractor SAN JOAQU IN PU MP CO. <br /> _ Type of Pump SUBMERGIBLE H.P. 5 HP <br /> PUMP REPLACEMENT:' ❑ State Work Done <br /> PUMP REPAIR: t I f - 11 State Work Done dNft <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 /> IHome 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." n <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 perso s subject to workman's compensation laws of California." <br /> I wl or a GrV Insp togroutingand a final inspection. <br /> Signed XA_ . . _ I - _ Title: OFFICE MGR, SAN JD ' _ _ PUM�tate:_ 1�-28-80 <br /> l (Draw Plot Plan on Reverse Side) 46 <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By i Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection L1 Pf se Final In ection <br /> Inspection By Date Inspection By!+� ate <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> t BILLING REMITTANCE $ REWT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> x DATE DATE REMITTED AMOUNT <br /> FEE 04�L j <br /> LESS <br /> PRORATION <br /> �.. <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1661 E.HAZELTON AVE,,P.O.Box 2069 STOCKTON,CA 95201 <br /> ' f <br />