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Applications Will Be Processed When Submitted Properly GOlnpieiea. De auro -%1- <br /> APPLICATION <br /> FOR OFFICE, <br /> (For Non-Transterable, Revocable, Suspendabie) PUMP&-w'"L <br /> ENVIRONMENTAL HEALTH PERMIT <br /> WATER QUALITY <br /> (COMPLETE IN TRIPLICATE) ork <br /> Application is hereby made to the SanJoaqun LOrdli Ordinance No a dora pthe rules and regulations oftthe San Joaquin)Local HealtthTDisthis ricphcation�s <br /> made in compliance with San Joaquin County R( ilorth side <br /> Exact Site Address 1 W. Gxantline Rd..-•600' East of Chr hone 835-7316 <br /> Da it Phone , <br /> Owner's Name Silva Bros. City Trac <br /> Address ___2317 W GTantline Rd 0 1 BusinessPhone <br /> Rennins Bros• License# 9 ---545-027-1 <br /> Contractor's Name Emergency Phone <br /> Contractor's Address :' <br /> is Certificate of Workman's Compensation Insurance.on File With SJLHD? Yes x No <br /> RECNDDESTRUCTION <br /> EN <br /> TYPE OF WORK (CHECK): NEW W A LM DEP ❑❑ OTH RO❑ ITIOp❑P INSTALLATION❑❑ PUMP REPAIR❑ Q <br /> WELL CHLORINATION El WELL �— <br /> REPLACEMENT❑ Pit Priv <br /> DISTANCE TO NEAREST: Septic Tank11101 Sewer Lines Pit <br /> Pit y Other <br /> Sewage Disposal Field Public Domestic Well ! <br /> Property Line Private Domestic Welk <br /> INTENDED USE } TYPE OF WELL 1 tt <br /> 11 INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation 6" PSC <br /> ❑ DRILLED Dia. of Well Casing 160 WALL <br /> M DOMESTIC/PRIVATE i❑ DRIVEN Gauge of Casing <br /> ❑ DOMESTIC/PUBLIC01 <br /> ® GRAVEL PACK Depth of Grout Seal <br /> ❑ IRRIGATION Type of Grout CEMENT <br /> 4 ElCATHODIC PROTECTION ROTARY Other Information 0--BY OWNER <br /> ❑ DISPOSAL ❑ OTHER DRILLER <br /> 3�Zpk� <br /> SurfacerSeal Installed By: i <br /> ❑ GEOPHYSICAL (lQ _�� C <br /> PUMP INSTALLATION: Cont ctor ClLntix�r —O <br /> Ty p <br />{ PUMP REPLACEMENT: Stat Work Done S 20 <br /> PUMP REPAIR: Sta e W Done <br /> DESTRUCTION OF WELL: <br /> Well 'a eto te Approximate Depth <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 <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I <br /> r <br /> Home owner or licensed agent's signature certifies the toliowing:"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 th workman's compensation laws of California. <br /> i <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." <br /> { i will tali for a Grout Inspection prior to grouting and a final inspeclio 5--1aSO <br /> 1 B <br /> SEC. Date: <br /> Signed X B 0 ( aw Plot Plan on Reverse Side) <br /> l FOR DEPARTMENT USE ONLY <br /> I PHASE 1 Date <br /> t <br /> i Application Accepted By <br /> Additional Comments: se III Fi Insp�on <br /> P se II Gra ection Inspection By Date <br /> ate <br /> Inspection By <br /> M1i ❑ EACH ❑ January 1'&Received By January 31 ❑ JuVy 1 &Received By July 31 <br /> F REMIT <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE <br /> ECKED <br /> BILLING REMITTANCE $ AMOUNT DUE CH <br /> I BASE EXPLANATION DATE DATE REMITTED AMDUNT <br /> -m <br /> FEE <br /> f LESS + <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Permit No. Issuance Date. Mailed ❑ ered <br /> Date Receipt No, __ _ _ <br /> Received by i - 1691 E.HAZELTON AVE.,P.O.Box 2049 OC_KTON,CA 95201 <br /> ��� <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - _ '�' T <br />