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<br /> licallons Will Be Processed Whom Submitted Properly ontpleted Op TO Sign The Appllca1114m r r 4'
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<br /> APPLICATION x iI
<br /> (For Non-Transferable Revocable,Suspendable) WELL.,
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<br /> 'PUMP&
<br /> W, ELL,,,q
<br /> ENVIRONMENTAL HEALTH PERMIT n; t
<br /> (COMPLETE IN TRIPLICATE) WATER QUALITY
<br /> Application Is hereby made to the San Joaquin Locat Health District for a permit to construct andJor Install the work herein des_crlbed This applECatlon is
<br /> made In compliance with San Joaquin County Ordinance No 1862 and the rules and regulations of the San Joaquin Local Health Dlslr ct;_i
<br /> 6553g;aterloo Rd. c�lylT,w1 Sto�ktQ :,��`�
<br /> r Exact Site Address — —
<br /> Frank Medina _ Phone
<br /> Owners Name — _ ..
<br /> Sarre �� ot}% `i:"y`}�°;tyT=i'+- r
<br /> �'k�•. Address
<br /> Contractor s Name r oQXrnaTt Srater Sy5t2TnS I_Icense a___!� 696 Business Phone
<br /> 4243 Ch err Ian ' _Emergency Phone F
<br /> Can actor s Address ___� �' --Sr��1�• 9 y ,
<br /> Sa Is Certificate of Workman s Compensation Insurance on File With SJLHD'r yes X
<br /> TYPE OF WORK (CHECK) NEW WELL❑ DE: 'EN C] RECONDITION❑ DESTRUCT$ONU
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<br /> ,# WELL CHLORINATION❑ WELi_ ABANDONMENT❑ OTHER ❑ PUMP INSTAL-TION ,PUMP REPAIRCI t. +
<br /> s REPLACEMENT❑ - ; '' }I ,1
<br /> DISTANCE TO NEAREST Septic Tank _. Sewer amines Pit Privy
<br /> ¢ \�' Sewage Disposal Freid_` Cesspool/Seepage Pit_ i Other
<br /> Property Line Private Domestic Well Public Domestic Well_— LZ ' ",,
<br /> INTENDED USE TYPE OF WELL j rJ -i;-`�� s`�i"�r ��1 , 1� "'k
<br /> U INDUSTRIAL E3 CABLE TOOL Dia of Well Excavation t,x s {fir } �� _
<br /> r❑ DOMESTIC/PRIVATE El DRILLED Oia of Well Casing_ -
<br /> : A E3DOMESTtC/PUBLIC _ C] DRIVEN Gauge of Casing ,q _ t~
<br /> ❑ IRRIGATION © GRAVEL PACK Depth of Grout Seal
<br /> ❑ CATHODIC PROTECTION 1 ❑ ROTARY -ype of Grout
<br /> C3DiSPOS4I: ° 13 OTHER 0'1^er Information
<br /> t ❑ GEOPHYSICAL Surface Seat lnstalred By-
<br /> -Ai
<br /> By �AaPUMP INSLLATIO Contractor M Orman s dater Systems
<br /> SIIleisle H waP�rrs �-"3 4
<br /> Type of Pump r.
<br /> exintinCATt A -'7PG " fan
<br /> PUMP REPLACEMENT State Work Done— -pulled
<br /> ' s't'^a�vl"]_►e'_�1"� �e*nwI�$"r"k`:
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<br /> PUMP REPAIR ,.w, s^ ❑ State Work Done
<br /> r .i 11�Je � ,, � [
<br /> "
<br /> DESTRUCTION OF,WELL Well Diameter r r�Aparaxlmate,Depth
<br /> 11, Describe Material and Proeed,Jre V r _ =`` �' '�♦Y ''f` ' "
<br /> . "
<br /> tlereby certify that I have prepared this application and that the work vill be done.n accordance w{ihtiSan Joaqul Coin[
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<br /> r _ ord/nances/state laws and rules and re ulat ons of the San Joaquin Local Heaith Distract "`* ' t . ' '' {
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<br /> =a [,5 If Home ovene•or licensed agents signature certifies the'following "{certify that in the perfoimanceof the work tOrwhrchth s permit +.
<br /> ,1':r Is issued I shall not employ any person in such manner as to become subject to workman s compensalio—;laws Df Calrfo
<br /> . _ a alS-ar<.'�1-'>ti`"
<br /> Contractors hiring or sub-contracting sign.ature Certllies. the following "I cerbty that in ttie perfor�z smance of the workfOrwhic th s }
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<br /> A ni e '�oermit is issued I shall employ persons subject to^wo kman s corripensat,on vCWs or Cal�flfor'rnia ; rtr
<br /> 1 Y+ '-I will cal!fora Grout Inspection prior to grouting and a�final inspection
<br /> r ' !T"i "�7 s� �.,� 1 2:T y tt �"•`ry
<br /> ed X" cz4r_.0 �-///� � — ` � Ti11e y I,,
<br /> �C i�tr ,✓// 7! (Draw Plot Plan on Relerse
<br /> Side)
<br /> `iet t FOR DEPARTMENT USE ONLY, Nz
<br /> PHASE 1 ti � tt `�i
<br /> Application Accepted By h'
<br /> Additional Comments
<br /> 17i may' + ' Phase li ' el In�'pection ' ,Lar, tl,
<br /> '* Phase It Grout Inspecti6n
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<br /> 'ns ection BX141k IV,
<br /> _ ate �'_ -7 �k7
<br /> Inspection By Date p 1 . tr
<br /> r � s
<br /> Fee Is Due © ANNUALLY ❑ PER UNIT PER 517E (�EACH ❑ Jaruary 1}d Received Hy"January31,-Y? r 13�8 Ree 7 I W f
<br /> ` r w 'I v}(( q i k r'v''11;K.'wi:T` "!js REWT 4r
<br /> " `y a!- T BASE EXPLANATION BILLING i REMITTANCE' + rs h +Y AMOUM U CHECKED
<br /> Yes;7�^� ,•t i r f DATE DATE REMITTED' i; �+�41' C3.i_$ pAAAOUHT •y
<br /> FEE
<br /> 'LESS �+ r r. , • - . �#,�
<br /> .LEORA'ftON "! t`r § •+ j *i n�' f�--��`t 7'W 1S s�` .�t.i" *1%,f 'rir�i�1 Y
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<br /> APPLICANT— RN ILL.COPIES T4' ENYIRUNMENTAL MEt LT"t 1M,T1SFPVtCEb 1601 IL HATELTON AVIS PO$'JON 9010E;I''STOClrr011.CA>�a7�y -
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