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J- Applications Will Be.Processed When Submitted Properly Completed. Be SureaegnThe Application. ^" [ ) <br /> APPLICATION . MAR Jif Jar <br /> `FOR-OFFICE USE: -,� � .. .. <br /> — (For Non-Transferable, Revocable, Suspendable) 1980 <br /> ) if n PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT ,1^[;rNt f "CAL <br /> (COMPLETE IN TRIPLICATE) <br /> WATER QUALITY HEALTH. �fS7 RT,T <br /> Application is hereby made to the San Joaquin Local Health Districtfora permit to construct and/or install the work herein described.This application is O�J <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. d <br /> Exact Site Address 3606 Guernsey St. r City/Town Stockton <br /> Carl Widmer Phone 465-6777 41- <br /> owner's Name <br /> Address - City. t <br /> Contractor's Name MachadoIris. License- 70�Q'7Business Phone 462-1424 <br /> Contractor's Address a Jack Tone Rd. Emergency Phone Same <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes X No r <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECONDITION 13 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP,INSTALLATION ❑ PUMP REPAIR <br /> REPLACEMENT❑� -W1 O(?• . _ , � - �. ,..: r - w . - .- <br /> DISTANCE TO NEAREST: r Septic Tank Pit Lines Pit Privy <br /> Sewage Disposal Field 25 Cesspool/Seepage Pit Other <br /> Property Line 50 a Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL __ - _ ElCABLE TOOL T Dia. of Well Excavation <br /> y _ — - <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ I]OMESTIC/PUBLIC"— -- (]-DRIVEN `"Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal f <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout W <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: d{ <br /> j <br /> PUMP INSTALLATION: � Contractor - <br /> Type of Pump} H.P, <br /> PUMP REPLACEMENT: ❑ State Work D"one <br /> PUMP REPAIR: State Work Done <br /> DESTRUCTION OF WELL: Well Diameter i Approximate Depth <br /> Describe Material and Procedure ; <br /> I hereby certify that-1 havepreparedthis application and that the work will be done in accordance with San Joaquin County <br /> r ordinances, state laws, and-rules and regulations of the San Joaquin Local Health District, <br /> I4- 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 /> ­­, ti.. <br /> Contractor's hiring or sub-contracting signnatu-re certifies the following:"I certify that in the performance of the work for-which this <br /> permit is issued, I shall employ persons subjecf to workman's compensation laws of California. <br /> I or a Grout Ins ion for to uting and a final inspection. <br /> V. .Pres. Date: <br /> Sign Title: <br /> �3"" <br /> (Draw Plot Plan on Reverse Side) +; <br /> j <br /> k FOR EPARTMENT USE ONLY <br /> t PHASE r - <br />+, Application Accepted By Date41-2 <br /> v <br /> j Additional Comments: 11 <br /> E Pha If Grout Inspection Phase 111 Final inspection l� <br /> Inspection By Date Inspection Byy• ` -� . Date <br /> Fee IS Due: [I ANNUALLY El PER UNIT [)(PER OSITE ❑ EACH ❑ January 4 &Received By January 31 ❑ July 1 &Received By July 31 <br /> I• - REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS- <br /> PENALTY— <br /> OTHER <br /> LUSPENALTYOTHER 3� <br /> OTHER t <br /> Received by Date _ Receipt No. Permit No. Issuance Date- Mailed Delivered <br /> a APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAXELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />