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P F Applications Will Be Processed When Submitted Property L:amplele e^4ju �� ,r <br /> �- Rnff ICE USE:y. APPLICATION T117 <br /> 1 <br /> - (For Non-Transferable, Revocable,Su able) p&WELL 1� <br /> V RONMENTAL HEALTH PER PER <br /> 4 '979 1.00 :�•: y t-� WATER QUALITY OQO tl <br /> (COMPLETE IN TRIPLICATE) �, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct an�Ns4IDj ,411 er(�gl tl �cribed.Thisapplicationis <br /> made in compliance with San oaquin County Ordinance No. 1862 and the rules and regulatioi4FDA{�tbET4nDO-%;Iu�16apal Health District. <br /> Exact Site Address 0001 Sout tl Woodbridge Rd.- Iii.East 99B—F ®igeTown T,odi <br /> ;•per's Nam.. <br /> iv!�teve Ka os Phone <br /> "• <br /> 8275 E. Orchi rd Road City <br /> Contractor's Name Furvianee Dri"llers Drilling Co]fpense# 37742 Business Phone--9_11- --446 <br /> Contractor's AddressP•©•Box 64,Tinden CalifEmergency Phone9.31-4468 <br /> r <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ® RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR© '- <br /> REPLACEMENT[k <br /> DISTANCE TO NEAREST: Septic Tank 1 ,000, Sewer Lines 1..0001 Pit Privy <br /> Sewage Disposal Field Cesspoo]/Seepage Pit Other <br /> Property Line Private Domestic Well 1 #0001 Public Domestic Well <br /> INTENDED USE TYPE OF WELL �J <br /> ❑ INDUSTRIAL ® CABLE TOOL Dia. of Well Excavation Existing 1411 <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia- of Well Casing t0 install 12-3/4" C Y C <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing •fig wo Y <br /> r ® IRRIGATION GRAVELPACK =' Depth of Grout Seal = - <br /> _ _ �..❑ ROTARY - :Type of-Grout - <br /> _ _ <br /> © CA THODIC-PROTECTION - Y <br /> ❑ DISPOSAL ❑, OTHER ,. - - ---Other-Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: { <br /> PUMP INSTALLATION: Contractor 4 <br /> Type of Pump H.P. <br /> { PUMP REPLACEMENT: '® State Work Done Re T ace existing 20 HP 'turbine Pura <br /> State Work Done ` <br /> ' PUMP REPAIR: ❑ <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> r f <br /> Describe Material and Procedure <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County' r. <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 fallowing:"I certify that in the performance of the work for which this permit`l- <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." t ; <br /> I will call for a r I pection prior to grouting and a final inspection. <br /> 1 Title: Pres. Date: 11/30/79 <br /> Signed.X s. <br /> f (Draw Plot Plan on Reverse Side) <br /> J' <br /> J <br /> FOR EPARTMENT USE ONLY <br /> f <br /> PHASE I .y 7 <br /> E Application Accepted By Date <br /> Additional Comments: <br /> Phase 11 Grout Inspection h se 111 Fin .Inspection' Inc <br /> k Inspection By Date A)A Inspection B Date <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By Januar 1 ❑ July 1 &Received By July 31 <br /> REMIT" <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE — o�t- <br /> LESS <br /> PRORATION <br /> s <br /> PLUS <br /> PENALTY - <br /> OTHER <br /> t <br /> j OTHER <br /> c7 3�q ly <br /> -7 <br /> Received by Date 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 />