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si•/a Applications Will Be Processed When Submitted Properly Completed.-Be SUM T Sipa TAe Application. r <br /> FOR OFOCCE USE: APPLICATION �J <br /> _?_1 (For Non-Transferable,Revocable,Suspe e� <br /> PUI WELL <br /> _.. ENVIRONMENTAL HEALTH PE t NOV 19 1980 <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is herebymadetotheSan Joaquin Local Health District fora permit toconstruct and'of3"llt e;wl kJt)�reiIptClescr_ibed.Thisapplicationis <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations e n Joap�Irz L cel i4�alth District. <br /> p G tY �},L�I-1 U i <br /> Exact Site Address IZ4ZO .� 1 XC7G.kRO. _ City.,Town <br /> Phone <br /> Owner's Name SJ,S.,�g5p1�Q1--���• — City_1�Cz�.�"Q�� � <br /> Address-T � ORAU2aN—;i ma�cc--`` ���� � <br /> Contractor's Name Cao-j! A Lf� AP.261P _ License a qQ3 l Business Phone=l�7 c�....._. <br /> Contractor's Address . O Q Emergency Phone 1-47 1 f <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ <br /> WELL CHLORINATION 11WELL ABANDONMENT ❑ OTHER C3PUMP INSTALLATION❑ PUMP REPAIR" <br /> REPLACEMENT❑ 2r� <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines_ Pit Privy <br /> Sewage Disposal Field— Cesspool/Seepage Pit . Other_ T"7 <br /> Property Line) .—Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL t <br /> INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation— <br /> El µ - —! <br /> a DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTICiPUBLIC _- <br /> DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑•.GRAVEL PACK Depth of Grout Seal •� <br /> _. <br /> ❑ CATHODIC PROTECTION <br /> 'ROTARY Type of Grout -- <br /> i❑ OT R', Other Information <br /> ❑ DISPOSAL — _ <br /> ❑ GEOPHYSICAL 11 `ti Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor — _ Aj I <br /> pe of Pump H.P.PUMP REPLACEMENT: Stale Work Don'JRA '�+—J- t �=�� �t1+� Vit- Q' �� IPUMP REPAIR: �R` <br /> State Work Done Et?YhP�2-3dh �iJL=nom SIS# P�KkP�lslon <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:1 certify that in theperformance of the work forwhich this permit <br /> Is issued, I shall riot 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 /> pPrrni't i ss I shall employ persons subject to workman's compensation laws of California;" ' 1 <br /> l w t G ut Inspection prior to grouting and a final Inspect' n. <br /> Signed X <br /> t Title: - Date: <br /> - <br /> j1 (Draw Plot Plan on R verse e) - <br /> 1 �� �^ .^"nJ T f <br /> 1 FOR DEPARTMENT USE ONLY Wim" — }. <br /> PHASE I Date )ICL fro <br /> Application Accepted By w — •- <br /> Additional Comments: L 2 a <br /> Phase 11 Grout Inspection /.,Ph a 10inal Ins tion/ 2 /0_0 <br /> Inspection By_ Date_ _ Inspection By vY ate 1 <br /> i If <br /> Fee Is Due:D ANNUAL'_' ❑ PER UNIT ❑ PEK SITE ElEA::N ❑ Ja^.uary 1 8 Recervetl By Ja-uary 31 C] J.iiy 1 8 Reolivld By July 31 <br /> ( ~riEM1T <br /> BASF E%PLANATION DATE DATC BILI INC, HEMtTTANCF I f AMOUNT DUE CHECKED - <br /> REMITTED AMOUNT <br /> FEE I ---- ---- - <br /> ( LESS 1� --- <br /> PRORATION - <br /> ( PLUS <br /> PENALTY - - -�-- - <br /> OTHER <br /> OTHER <br /> 0 SS CL <br /> necerved by Date Kere-pt Nu Per'nit No. ssuaoce Date Mailed Deavere4 ` y� <br /> 1{� APPLICANT—RETURN ALL COPIES TO: .ENVIRONMENTAL HEALTH PERMIT/SERVICES •1601 E NAZELTON AVE..P.O.so.2009 ��S�TcOCKTON:CA 95201 <br />