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Applications Will � odl'.�s' ifd`VFI*ni, L(bmitted Property Completed Be "r c�§IOWTfWAVPIICa><toru <br /> _FOR O,FICE USE: ff jj L t ° TONU Lk <br /> lll���y��� (For Non-Transfer I a ocable,Suspendable MAR 5 p&WELL <br /> { A�EIMRO NT EALTH PERMIT _ <br /> COMPLETE IN TRIPLICATE SAN WATER QUALITY SAN '' ` � t� A� <br /> ( 1;�1 nr;?Jk, R IS <br /> Application is hereby made to the San JoaquiW,REt—y altlr�Drl`�''tri6 fkrm ermittoconstructand/orinstallt ei s I .This application is <br /> made in compliance with San Joaquin County OrdinanceQ"3� @rjd tt11e rules and regulations of the San Joaquin Local Health District. <br /> Exact Site Address 2 144 Bird Road City/Town TracCA <br /> Owner's Name C & A Navarra R.3I3C("t, Inc. Phone <br /> 209/836-0005 <br /> Address 75W. Blewett Road City Tracy, CA 76 <br /> Contractor's Name W�Bterll Well Drilling CO. ,Ltd0 License# 25182 Business Phone 408 295-4332 <br /> Contractor's Address P•0- Box 109, Sari Jose CA 95103 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No j <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION® DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR® l <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 lin _ <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC%PUBLIC ❑ DRIVEN Gauge of Casing D6uble 10 gauge <br /> IN IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout - - - <br /> ❑ DISPOSAL ❑ OTHER" '-Other Information <br />` <br /> E] GEOPHYSICAL _ Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Typ6of Pump ( _ H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done—, <br /> PUMP REPAIR: ❑ State Work Done Bowl and column repair <br /> I DESTRUCTION OF WELL: Diameter Approximate Depth <br /> - ¢ b9cribe 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 for which this <br /> permit is issued, I shall employ persons subject w kman's compensation laws of California." <br /> I <br /> will call spection prior 10 groutin and final inspection. <br />' SignedX Tttl'e: President ,.r. Date: March 4, 1981- <br /> (Dra of Plan on Reverse Side) - � <br /> FOR DEPARTMENT USE ONLY <br />" PHASE I <br /> Application Accepted By 1 - Date <br /> Additional Comments: <br /> Phase.II Grout Inspectionspection <br /> Inspection By Date Inspection By II al inDate , <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _ ❑ PER SITE ❑ EACH ❑ January 1 &Recyw By January 31 ❑ July 1 &Received By July 31 <br /> Y REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE 4 <br /> .42.jv^ Y <br /> !LESS <br /> I .PRORATION <br /> -PLUS fi <br /> ` PENALTY <br /> e - - <br /> OTHER L <br /> OTHER <br /> 33 �S <br /> Onrciocri hu ate Receict-No .t No Issuance Date Mailed Delivered <br />