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Applications Will Be Processed When Submitted ProperlyCompletes. liesure 10 sign 1ne►;NYn�a"�" , <br /> FOR oFF.lcs usE: APPLICATION .4 <br /> - ,� <br /> (For Non-Transferable, Revocable,Suspendable) PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (CO A7 <br /> Application is herebymadetotheSanJoaquinLocalHealthDistrictforapermittoconstructand/orinstalltheworkhereindescriealthDisrictapplication 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_Lot #11 Stonerid> e Stab--div cin City/Town <br /> 4189 Bockv Point Ctei <br /> Owner's Name Dori COSe fit: Assoc• Phone <br /> Address P.O. Box 26 City <br /> Contractor's Name HeT11liTl S BrOS License# 29x_81_1- Business Phone_ 545-1185 r <br /> Contractor's Address 2 Pelanda1e Modesto Emergency Phone 545-0271 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No ) <br /> TYPE OF WORK (CHECK): NEW WELL It DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ C <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank 1001+ Sewer Lines Pit Privy <br /> a Sewage Disposal Field Cesspool/Seepage Pit Other 1♦— <br /> i Property Line Private Domestic Well Public Domestic Well fs <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> — <br /> M DOMESTIC/PRIVATE 11 PVC <br /> is <br /> p 13DRILLED Dia. of Well Casing Or <br /> Y <br /> ❑ DOMESTIC/PUBLIC <br /> 11 DRIVEN Gauge of Casing � - WALL— <br /> 1:1IRRIGATION 10 GRAVEL PACK Depth of Grout Seal 01 <br /> t ❑ CATHODIC PROTECTION M ROTARY Type of Grout CEMENT <br /> ❑ DISPOSAL ❑ OTHER Other InformationSLAB—BY <br /> ❑ GEOPHYSICAL Surface Seal Installed By: DRILLER <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump .- H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> f <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 /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this per <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> f 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." <br /> I will call for a Grout Inspection prior t,U.gro�uting and a final inspect' <br /> Signed X <br /> BENNINGS BROS. BY Vie! SEC-. Date: 5-15. 80 <br /> i ( raw Plot Plan on Reverse Side) <br /> FO EPARTMENT USE ONLY <br /> PHASE I Date O <br /> Application Accepted By <br /> l Additional Comments: <br /> is Phil e l ut Inspection y7��6 Phase 111 final Inspection <br /> Inspection B /� _y_1r Date— Inspection By - Date <br /> Fee Is Due: ❑ ANNUALLY 1 LJ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 El July 1 &ReceivedREMIT <br /> uIy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> �t �3 <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 6 <br /> OTHER <br /> —/'? 461 30 331b 0sB3 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed d <br /> ST CKTON;CA 55201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES: 1601 E.HAZELTON AVE.,P.O.Bax 2009' <br />