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FOR OFFICE_USE: APPLICATION <br /> (For Non-Translerable. Revocable.Suspendable) <br /> PUti1P 8.V,,r[LL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Appl cat,an is hereby made to the Sari Joaquin Local Health Districtfor a pe rmill ro corstrurl and nor install the worK here:n described This apps cation is <br /> M; compliance with San Joaquin County Ordinance No 18V and[tie rules and regulations of the San Joaquin Local Hearin District <br /> Exa, mite Address 14600 5• Austin Rd _ Coy,Towel Manteca <br /> Owner's Name Mantec-a Unf ied School District Phone 239-1279 <br /> Address ____ 2901 E. Louise ,Mbcx __32 City Manteca - <br /> Contractot's Naine Clark Well & E4aipment L cense o 371560 Business Phone 462--.5597 r <br /> Contractors Address 2024 E. Charter--Way Emergency Phone I`IA — (n <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No - <br /> TYPE OF WORK (CHECK). NEW WELL 5a DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ _.! <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION❑ PUMP REPAIRE) <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST Septic Tank 135' Sewer I Ines Pit Privy <br /> Sewage Disposa kFetc _ Cesspool'Seepagv Pit — _ Other <br /> Property Line-1-41, Prtvaie Domestic Wet, Public Domestic We`•� <br /> INTENDED USE TYPE OF WELL <br /> ❑ INOUSTRIAL ❑ CABLE TOe)I Dta. of Weil Excavation —_14'I — <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED L)ia. of Well Casing _- 10" — <br /> ® DOMESTICIPUBLIC ❑ DRIVFN Gauge of Casing - <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal — <br /> ❑ CATHODIC PROTECTION 0 ROTARY Type o1 Grout _ —9-8=k mix <br /> ❑ DISPOSAL 13 OTHER OthEr Information <br /> _. .. <br /> ❑ -EOPHYSICAL Surface Seal Instal ed By — <br /> PUMP INSTALLATION: Contractor --- <br /> '•vo&of Pump H P <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> O <br /> PUMP REPAIR: ❑ State Work Done - <br /> D' IUCTION OF WELL: Well Diameter —_ -- Aphro timate Depth _ (/1 <br /> Descrcpe Material and Procedure <br /> I hereby certify that I I)ave prepared this application and that the work will be done in accordanre with San Joaquin County <br /> ordinances state caws, and rules and rPgulat(ans of fine San Joaquin Local Health D,stnct <br /> Home owner or licensed agent-s signature eertllies the following:'l certity that in the performance of the work for which this permtt <br /> .s i99uea, 1 ;hall nc)t i�niploy any persor, in such man-or as to become subject to workman's compensalion 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 /> permit is issuOd I shall employ persurss Su wot tan's •umpenSation laws of California <br /> 1 will call for a Grout Inspection 1 o n a ns ection. <br /> Signed X Michael R. Clark_- . F_CLARK WELL - _ Date: August 4,1981 <br /> (Draw Pint Pla:i or Reverse S,dn:• <br /> n FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By <br /> Additional Comments -- -- <br /> P se 1 Grout inspection Phase 111 Final Inspection I <br /> Inspect on By Dale inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PFR UNIT D PER SITZ: EACH ❑ Jan..ary 1 8 Rec4e.ved By January 7' ❑ a r;.•..••,,._: G•. !.i. <br /> -- -i --- �- _— _I-- _ — HEM, <br /> BASE EXPLANATION � BILLING REMITTANCE S ANOVNT(jJE CHECKrO <br /> -- DATE DATE I REMITTED AMO_uvT____- <br /> FEE <br /> _ _ - <br /> LESS <br /> PRORATION <br /> PLUS !- - <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 5; erred by Date ReLe-01 No -- Permit No �� �ts. ante 31A � wallee )e wt (�jJ <br /> APPLICANT—RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMfTrSERVICES 1601 E HAZ[LTON AVE.PO B0,2009 STOCKTON,CA IIN <br />